Every finding on record at Southern Ocean Center

Based on interviews, medical record reviews and reviews of other pertinent facility documentation on 3/2/26 and 3/3/26, it was determined the facility failed to ensure that medical records for residents were accurate as evidenced by a.) an inaccurate weight being entered for a Resident #5 b.) the Licensed Practical Nurse (LPN) who did not sign out the Medical Administration Record (MAR) after administering (Resident #8) and c.) nurses clicking the wrong button under Nutrition while documenting their skilled evaluations for a Resident #4. This resulted in inaccurate medical records and failure to identify potential medication, weight, and documentation errors. This deficient practice was identified for 3 of 10 residents reviewed for resident records (Resident #4, Resident #5 and Resident #8), and was evidenced by the following:A. On 3/2/26 the surveyor reviewed Resident #5's documented weights while at the facility. Resident #5 had a weight of 166.5 pounds on 11/28/25 and 150 pounds on 11/29/25.According to the admission Record (AR) face sheet, Resident #5 was admitted to the facility with diagnoses including but not limited to: heart failure, unspecified atrial fibrillation (common heart arrhythmia characterized by an irregular, rapid heart rhythm caused by chaotic electrical signals in the heart's upper chambers), and respiratory disorder.According to the Minimum Data Set (MDS), an assessment tool dated 12/8/25, Resident #5's Brief Interview for Mental Status (BIMS) was a 15 which indicated that Resident #5 was cognitively intact.On 3/2/26 at 11:25 AM, the surveyor interviewed an LPN from the facility's Post Acute Care Unit (PACU) who stated that if a resident was gaining or losing too much weight, the staff would notify speech and dietary.On 3/2/26 at 11:31 AM, the surveyor interviewed the Unit Manager (UM) of the PACU. In relation to a resident's weight gain or loss, she stated she would inform the doctor, confirm the weight change, and aid the resident to support the weight gain or loss. The UM stated that depending on what the resident and family wants, the care team is informed, and a decision is made collaboratively to address weight gain or loss.On 3/3/26 at 12:08 PM, the surveyor interviewed a CNA from the facility's Lighthouse unit who stated that CNAs are responsible for taking a resident's weight. She stated that typically she would weigh a resident and compare the weights for a 2-pound weight gain or loss. If there was a weight gain or loss greater than 2 pounds, she would reweigh the resident. The CNA also stated she did not think a 15-pound weight loss would occur in a day but that she would notify the nurse so that the nurse could address the situation. On 3/3/26 at 12:12 PM, the surveyor interviewed the UM of the PACU unit who stated a resident with a 15-pound weight loss would lead to nutrition reaching out to her to notify her of the weight loss. At this time, the surveyor showed the UM the weights for Resident #5. The UM stated she is not sure what happened and that her CNAs know to notify the nurse and nutrition related to weight loss such as Resident #5's. She stated that it was probably an error.On 3/3/26 at 12:44 PM, the surveyor conducted a phone interview with one of the facility's nutritionists. She stated that nutrition typically gets a weight trigger for a 15-pound weight loss and that nutrition would email the UM and ask for a re-weight and ask for further clarification and the team would analyze the weight loss.On 3/3/26 at 1:02 PM, the surveyor interviewed the Director of Nursing (DON). The DON showed Resident #5's weights as well as the facility's policy regarding resident weights. The DON stated that based off what the surveyor was showing her and stating related to Resident #5, the facility policy was not followed and that she believed that Resident #5's weight from 11/29/25 was a mistake.B. On 3/3/26 the surveyor reviewed Resident #8's February 2026 MAR. For 2/14/26, the MAR for oxycodone was blank on 12/14/26.According to the AR face sheet, Resident #8 was admitted to the facility with diagnoses including but not limited to: displaced intertrochanteric fracture of right femur (a common, severe hip fracture occurring between the greater and lesser trochanters of the upper right thigh bone), subsequent encounter for closed fracture with routine healing, muscle weakness, and other abnormalities of gait and mobility.According to the MDS, dated [DATE], Resident #8's BIMS was an 8 which indicated that Resident #8's cognition was moderately impaired.On 3/2/26 at 11:13 AM, the surveyor interviewed an LPN from the facility's PACU unit regarding medication administration documentation. The LPN stated medications are signed out on the MAR and the expectation is to be documented in real time as the medication is being given.On 3/2/26 at 11:31 AM, the surveyor interviewed UM of the PACU unit. When asked what her expectations are when it comes to documentation the UM stated she expects all her staff to fill out their required documentation including MARs.On 3/3/26 at 1:02 PM, the surveyor interviewed the DON who stated that her staff are well educated and trained in documentation and facility policies.C. On 3/3/26 the surveyor reviewed Resident #4's Nursing Advanced Skilled Evaluations ([NAME]) and three nurses had clicked the wrong button under Nutrition which created documentation errors for Resident #4.According to the AR face sheet, Resident #4 was admitted to the facility with diagnoses including but not limited to: encounter for surgical aftercare following surgery on the circulatory system, pneumonitis (general inflammation of the lung tissue) due to inhalation of food and vomit, and acute respiratory failure with hypoxia (oxygen deficiency).According to the Social Services Assessment and Documentation dated 2/24/26, Resident #4's BIMS was a 9 which indicated that Resident 4's cognition was moderately impaired.On 3/3/26 at 9:53 AM the surveyor conducted a phone interview with one of the LPNs who had been inaccurately documenting Resident 4's [NAME]. The surveyor asked the LPN if the [NAME] was an attestation for a head-to-toe assessment for a resident and she replied yes.On 3/3/26 at 12:12 PM the surveyor interviewed the UM of the PACU unit who confirmed that the [NAME] was the nurse's head-to-toe assessment for a resident and expectation is that it is to be completed daily. She further stated that staff are to be doing a new and daily [NAME] per shift and that staff need to pay attention to what they are documenting because their documentation is their attestation.On 3/3/26 at 1:02 PM, the surveyor interviewed the DON who confirmed that she also expects her staff to complete a new [NAME]. The DON also stated that staff should document accurately as one shift can be different from another and that things change. She also stated she was not sure what was occurring with her staff's documentation regarding Resident #4's NASEs. The surveyor pointed out that under the Nutrition the nurses were clicking met for where the [NAME] was asking if residents were Taking nutrition and hydration orally. No complaints of thirst. No signs/symptoms of a swallowing disorder. Mucous membranes moist. The DON confirmed what the surveyor pointed out and then stated she could see how this could be confusing for her staff and that is why they were incorrectly clicking it. The surveyor pointed out that 3 nurses made this documentation error, but other nurses did not for Resident #4.A review of the facility's policy titled NSG113 Nursing Documentation with a revision date of 5/1/23, included the following information under Policy: Nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate based on the resident's/patient's (hereinafter patient) condition, situation, and complexity. A review of the facility's policy titled OPS402 Clinical Record: Charting and Documentation with a revision date of 7/15/25, included the following information under Purpose: to provide a complete account of the patient's total stay from admission through discharge, provide information about the patient that will be used in developing a plan of care, and as a tool for measuring the quality of care provided to the patient. Under, Process:2. Licensed staff and interdisciplinary team members shall document all assessments, observations and services provided in the patient's medical records in accordance with state law.3. Document pertinent changes in the patient's condition, reaction to treatment, medication, etc., as well as routine observations.4. Documentation shall be completed at the time of service, but no later than during the shift in which the assessment, observation, or care service occurred.6. Principles of documentation include but are not limited to the following. 6.1 Documentation shall be factual, objective, and patient centered.A review of the facility's policy titled NSG 244 Weights and Heights with a revision date of 1/15/26, included the following information under Policy: Based on the patient's comprehensive assessment, the Center will ensure that all patients maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, . Under, Purpose: To obtain baseline weight and identify significant weight change. To determine possible causes of significant weight change. Under, Process: 2. If the body weight of a patient is not as expected, re-weigh the patient.NJAC 8:39-35.2

Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 3/2/26 and 3/3/26, it was determined that the facility failed to ensure staff properly wore the appropriate personal protective equipment (PPE) when providing care for patients on Enhanced Barrier Precautions (EBP) for four residents (Resident #1, Resident #7, Resident #9 and Resident #10). The facility also failed to follow its policy titled IC 308 Enhanced Barrier Precautions. This deficient practice was identified for 4 of 10 residents reviewed for infection prevention and was evidenced by the following:According to Resident #1's admission Record (AR), the resident was admitted with diagnoses that included but were not limited to: periprosthetic fracture around internal prosthetic left hip joint (a break in the hip socket next to a hip implant), presence of left artificial hip joint, and heart failure.According to the Minimum Data Set (MDS), an assessment tool dated 2/14/26, Resident #1's Brief Interview for Mental Status (BIMS) was a 15 which indicated that Resident #1 was cognitively intact.According to Resident #1's Care Plan (CP) with a date initiated of 2/8/26, under Interventions stated: Enhanced Barrier Precautions: Enhanced Barrier Precautions: Use gown and gloves when performing high-contact activities: dressing, bathing and showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device (e.g. central line, urinary catheter, feeding tube, tracheostomy, or ventilator), wound care (any skin opening requiring a dressing).According to Resident #7's AR, the resident was admitted with diagnoses that included but were not limited to: right hip bursitis (the painful inflammation of a small, fluid-filled sac that acts as a cushion to reduce friction between bones, tendons, and muscles near joints), pain in right hip, and unilateral primary osteoarthritis of right hip (a chronic, degenerative joint disease affecting only the right hip, characterized by the gradual wear and breakdown of articular cartilage without a known underlying cause).According to the MDS, dated [DATE], Resident #7's BIMS was a 15 which indicated that Resident #7 was cognitively intact.According to Resident #7's CP with a date initiated of 1/30/26, under Interventions stated: Enhanced Barrier Precautions: Change PPE before caring for another [name redacted].According to Resident #9's AR, the resident was admitted with diagnoses that included but were not limited to: nutritional anemia (a condition caused by a deficiency of nutrients-most commonly iron, folate, or vitamin B-12), Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out daily tasks), and rheumatoid arthritis (chronic, autoimmune disease where the immune system mistakenly attacks the lining of joints, causing painful inflammation, stiffness, and potential bone erosion or deformity).According to the MDS, dated [DATE], Resident #9's BIMS was a 9 which indicated that Resident #9's cognition was moderately impaired.According to Resident #9's CP with a date initiated of 4/3/25, under Interventions stated: Enhanced Barrier Precautions: Use gown and gloves when performing high-contact activities: dressing, bathing and showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device (e.g. central line, urinary catheter, feeding tube, tracheostomy, or ventilator), wound care (any skin opening requiring a dressing).According to Resident #10's AR, the resident was admitted with diagnoses that included but were not limited to: acute cystitis with hematuria (common infection that causes inflammation, resulting in painful, urgent urination and blood in the urine), malignant neoplasm of prostate (a cancerous tumor that develops from cells in the prostate gland), and peripheral vascular disease (slow, progressive circulation disorder caused by the narrowing, blockage, or spasms of blood vessels outside the heart and brain, most commonly in the legs).According to the MDS, dated [DATE], Resident #10's BIMS was a 15 which indicated that Resident #10 was cognitively intact.According to Resident #10's CP with a date initiated of 4/3/25, under Interventions stated: Enhanced Barrier Precautions: Use gown and gloves when performing high-contact activities: dressing, bathing and showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device (e.g. central line, urinary catheter, feeding tube, tracheostomy, or ventilator), wound care (any skin opening requiring a dressing).On 3/2/26 at 9:24 AM, the surveyor observed the lab technician with no PPE on who was finishing up lab work for Resident #7 in their room.On 3/2/26 at 9:53 AM, the surveyor observed a therapist who was transporting Resident #1 to therapy with no PPE while in Resident #1's room. Resident #1 also questioned staff in the room, such as the Unit Manager and Certified Nursing Assistant (CNA) who did have the appropriate PPE on, why they had a yellow gown on.On 3/3/26 at 9:20 AM, the surveyor observed a staff member in scrubs in Resident #9's room. At this time, the staff member appeared to be exiting Resident #9's room with the Hoyer lift. However, on 3/3/26 at 9:23 AM, the surveyor passed Resident #9's room again and observed the same staff member was utilizing the Hoyer lift for Resident #9 with just gloves on and no gown.On 3/3/26 at 9:21 AM, the surveyor observed another staff member in Resident #10's room providing care with Resident #10 in the bed who also had gloves on and no gown.On 3/2/26 at 10:52 AM, the surveyor interviewed a CNA from the facility's Garden Unit who stated that residents who are on EBP have signs outside their door to indicate they are on EBP. She stated that if direct care is provided, PPE is supposed to be worn.On 3/2/26 at 11:25 AM, the surveyor interviewed a Licensed Practical Nurse (LPN) from the facility's Post Acute Care Unit (PACU) who stated that EBP residents have signs on the door to indicate which type of isolation precautions a resident should be on. She stated that if staff enter that resident's room, they should always have PPE on so that infection does not spread. The LPN further stated that with all care, staff are expected to have PPE on for residents with EBP.On 3/2/26 at 12:38 PM, the surveyor interviewed the Director of Nursing (DON) who stated that EBP residents have signs outside the rooms and that all staff are educated on EBP and that the expectation is for staff to have the proper PPE on.On 3/3/25 at 1:50 PM, the surveyor interviewed the DON and the Licensed Nursing Home Administrator (LNHA) together. The surveyor asked when staff would be expected to where the appropriate PPE for EBP. They stated that if staff are touching the bed, providing care, touching wounds or catheters, or in direct contact with a resident they should have the appropriate PPE on.Review of the facility policy titled, IC308 Enhanced Barrier Precautions with a revision date of 11/14/25 under POLICY states:In addition to Standard Precautions, Enhanced Barrier Precautions (EBP) will be used (when Contact precautions do not otherwise apply) for novel or targeted multi-drug resistant organisms (MDROs).EBP expands on the use of gown and gloves beyond anticipated blood and body fluid exposures, focusing on use of gown and gloves only during high contact patient care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body exposure is not anticipated.Under Purpose: to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact.N.J.A.C. 8:39-19.4(n)

This deficient practice was evidenced by the following: On [DATE], from 08:47 AM to 09:39 AM, during the kitchen tour, the surveyor, accompanied by the Dietary Director (DD), observed three gallons of unopened whole milk in the walk-in refrigerator. The manufacturer's expiration date on the milk was [DATE]. On [DATE] at 8:47 AM, during an interview with the surveyor, the Dietary Director (DD) stated that the expired milk would be discarded, and that expired milk could cause illness. A review of the undated facility policy titled, Use By Dating Guidelines, revealed that .The manufactures' expiration date, when available, is the use by for unopened items. N.J.A.C 8:39-17.2 (g)

Based on observation, interview, review of medical records, and other pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices during a COVID-19 outbreak, specifically the a.) use of Personal Protective Equipment (PPE) for 2 unsampled residents (Resident #46 and Resident #105) and 1 resident (Resident #3) reviewed for tube feeding on transmission-based precautions, b.) handling of clean linen during transport in the nursing unit on COVID-19 outbreak, and c.) hand hygiene for residents in the dining room, to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice. This deficient practice was evidenced by the following:Reference: As SARS-CoV-2 transmission in the community increases, the potential for encountering asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection also likely increases. In these circumstances, healthcare facilities should consider implementing broader use of respirators and eye protection by HCP during patient care encounters as described. Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) worn during all patient care encounters. https://www.cdc.gov/covid/hcp/infection-control/index.html Reference: Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html Reference: When patients and visitors should clean their hands: Before preparing or eating food.How to clean hands: With an alcohol-based hand sanitizer.With soap and water. https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html A.1.) On 9/3/2025 at 8:57 AM, Surveyor #1 observed Nurse Practice Educator/ Registered Nurse #1 (NPE/ RN #1) wearing N95 mask and eyeglasses, sanitize their hands and don yellow disposable gown and gloves outside the room of Resident #105. The eyeglasses did not have covers on the side. The surveyor observed a signage for droplet precautions along the doorway which indicated that staff had to wear gown, gloves, N95 mask, eye protection or face shield. The signage also indicated that staff was required to keep the door closed. The surveyor observed NPE/ RN #1 leave the door open and assist Resident #105 to the wheelchair. A review of the Resident #105's electronic medical record (EMR) revealed the following: A review of the admission Record reflected the resident had diagnoses that included but not limited to COVID-19, decreased white blood cell count, and dementia. A review of the most current comprehensive Minimum Data Set (MDS), an assessment tool dated 8/1/2025 revealed that the resident had a Brief Interview for Mental status (BIMS) of 7 which indicated a severely impaired cognition. The MDS also indicated that the resident required moderate assistance for transfers. A review of the clinical physician orders active as of 8/26/2025 revealed an order for droplet precautions. A review of Resident #105's most current comprehensive care plan initiated on 8/26/2025 reflected a focus for COVID-19 infection diagnosis with interventions which included droplet precautions. On 9/4/2025 at 10:30 AM, during an interview with the surveyor, the Infection Preventionist (IP) stated that the facility was on active COVID-19 outbreak which started last 8/17/2025. The surveyor asked the IP what PPE staff is expected to wear inside residents with COVID-19 infection. The IP stated that inside the rooms of residents with COVID-19 infection, the staff are expected to observe droplet precautions which meant they must wear N95 mask, gown, gloves, and protective eye gear like face shield and goggles. The IP also stated that eyeglasses need to have side cover for protection. On 9/5/2025 at 11:37 AM, during an interview with the survey team, the Director of Nursing (DON) stated that staff should be wearing gown, N95 mask, gloves, and face shield inside the room of a COVID-19 positive resident. The DON also stated that staff should not be using eyeglasses for eye protection because eyeglasses have open sides and that the sides should be closed. A review of the facility-provided policy revised on 5/1/2025 titled Transmission Based Precautions included under droplet Precautions the following: 10.6 Based upon the pathogen or clinical syndrome, if there is a risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield) should be worn. 2.) On 9/3/2025 at 9:00 AM, Surveyor #1 observed Licensed Practical Nurse (LPN) #1 enter the room of Resident #46 wearing yellow gown, gloves, N95 mask and brown eyeglasses. The eyeglasses did not have covers on the side. The room had a signage along the doorway for droplet precautions. The surveyor observed LPN #1 close the door. On 9/3/2025 at 9:03 AM, Surveyor #1 observed LPN #1 leave Resident #46's room wearing the brown eyeglasses. LPN #1 continued to wear the brown eyeglasses while doing medication administration in the nursing unit. On 9/3/2025 at 12:35 PM, Surveyor #1 observed Registered Nurse/ Unit Manager (RN/ UM) enter Resident #46's room wearing N95 mask, yellow gown, and gloves. RN/ UM was not wearing eye protection. A review of the Resident #46's electronic medical record (EMR) revealed the following: A review of the admission Record reflected the resident had diagnoses that included but not limited to COVID-19, metabolic encephalopathy (a condition where the brain's metabolism is disrupted leading to altered brain function), and chronic obstructive pulmonary (lung) disease. A review of the most current comprehensive Minimum Data Set (MDS), an assessment tool dated 8/29/2025 revealed that the resident was on isolation precautions for an active infectious disease under section O. A review of the clinical physician orders active as of 8/24/2025 revealed an order for droplet precautions. A review of Resident #46's most current comprehensive care plan revised on 9/3/2025 reflected a focus for risk of respiratory complications related to recent hospitalization. On 9/4/2025 at 10:30 AM, during an interview with the surveyor, the Infection Preventionist (IP) stated that the facility was on active COVID-19 outbreak which started last 8/17/2025. The surveyor asked the IP what PPE staff is expected to wear inside residents with COVID-19 infection. The IP stated that inside the rooms of residents with COVID-19 infection, the staff are expected to observe droplet precautions which meant they must wear N95 mask, gown, gloves, and protective eye gear like face shield and goggles. The IP also stated that eyeglasses need to have side cover for protection. On 9/5/2025 at 11:37 AM, during an interview with the survey team, the Director of Nursing (DON) stated that staff should be wearing gown, N95 mask, gloves, and face shield inside the room of a COVID-19 positive resident. The DON also stated that staff should not be using eyeglasses for eye protection because eyeglasses have open sides and that the sides should be closed. A review of the facility-provided policy revised on 5/1/2025 titled Transmission Based Precautions included under droplet Precautions the following: 10.6 Based upon the pathogen or clinical syndrome, if there is a risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield) should be worn. 3.) On 9/3/2025 at 12:24 PM, Surveyor #1 observed Licensed Practical Nurse (LPN) #2 administer water flush and a bolus feeding (a method of administering liquid food or medication through a tube directly into the stomach or small intestine) of formula Jevity 1.5 cal to Resident #3 who was sitting in a wheelchair. LPN #2 was wearing N95 mask and gloves. LPN #2 was not wearing protective gown. On the doorway of the resident's room, there was a signage for Enhanced Barrier Precautions (EBP) (an infection control strategy that uses gloves and gowns during high-contact resident care). The signage indicated staff to wear gown and gloves when providing high-contact direct care for residents. The examples given in the signage for high-contact direct care included device care or use like feeding tube. A review of the Resident #3's electronic medical record (EMR) revealed the following: A review of the admission Record reflected the resident had diagnoses that included but not limited to gastrostomy status (a medical condition where a surgical opening is created in the stomach to provide direct route for feeding), acute cough, and cerebral infarction (stroke). A review of the most current comprehensive Minimum Data Set (MDS), an assessment tool dated 8/4/2025 revealed that the resident was on feeding tube. A review of the clinical physician orders active as of 4/15/2025 revealed an order for enhanced barrier precautions for tube feeding. A review of Resident #3's most current comprehensive care plan revised on 8/8/2025 reflected a focus for enteral tube feeding with interventions which included enhanced barrier precautions. On 9/4/2025 at 10:30 AM, during an interview with the surveyor, the Infection Preventionist (IP) stated that the facility was on active COVID-19 outbreak which started last 8/17/2025. The surveyor asked the IP what PPE staff should be wearing for residents on EBP. The IP stated that staff should be wearing gown and gloves during high-contact activities such as g-tube (tube feeding) feedings. On 9/5/2025 at 11:37 AM, during an interview with the survey team, the Director of Nursing (DON) stated that staff should be wearing gown and gloves for residents on EBP during high-contact activities that included g-tube feeding. A review of the facility-provided policy revised on 12/16/2024 titled Enhanced Barrier Precautions indicated under Process 4. Use EBP when patient status included wound or indwelling medical device without secretions or excretions that are unable to be covered or contained and not known to be infected or colonized with any MDRO (multi-drug-resistant organisms). B.) On 9/3/2025 at 11:51 AM, Surveyor #1 observed a yellow housekeeping cart outside a resident's room with a big plastic bag tied on the handle. The plastic bag contained clean-looking multi-colored washcloths touching the floor in the hallway. The surveyor also observed Housekeeper (HSK) #1 mop the floor of the resident's room nearest the cart. The surveyor asked HSK #1 to identify the content of the plastic bag which they identified as clean rugs. HSK#1 was observed wheeling the cart in the hallway dragging the plastic bag along with it. On 9/4/2025 at 10:30 AM, during an interview with the surveyor, the IP stated that clean linen should not touch the floor. On 9/5/2025 at 11:37 AM, during an interview with the survey team, the DON stated that clean rugs in plastic bag should not touch the floor for infection control. A review of facility-provided policy revised on 5/1/2024, titled Linen Handling included under Policy: All linen will be handled, stored, transported, and processed to contain and minimize exposure to waste products. Under Definitions: Linen includes sheets, blankets. washcloths, and similar items from departments such as .environmental services. C.) On 09/03/2025 at 11:40 AM, Surveyor #2 observed dining for lunch in the 1st floor dining room. The IP provided the residents in the dining room with moist towelettes for hand hygiene. The moist towelettes were alcohol free. During an interview with Surveyor #2 on 09/03/2025 at 11:55 AM, the IP stated that residents receive towelettes for hand hygiene prior to meals. She added that she was not sure whether the towelettes contain alcohol and that they should suffice and are good enough. During an interview with Surveyor #1 on 09/05/2025 at 11:37 AM, the LHNA stated that staff should ensure residents use alcohol-based hand sanitizer before meals to help prevent the spread of germs. He clarified that the wipes are intended for cleaning residents' hands and faces after consuming messy foods, such as ribs, to remove visible sauce or residue. A review of a facility policy dated 05/01/2025 titled, Hand Hygiene, revealed that, Per the Centers for Disease Control and Prevention (CDC), when hands are not visibly dirty, alcohol-based hand sanitizers are the preferred method for hand hygiene. N.J.A.C. 8:39-19.4(a)(1)(m)(n) N.J.A.C. 8:39-21.1(d)

Based on interview, record review, and review of the facility's policy, the facility failed to implement their abuse policies and procedures by ensuring a resident (Resident #104) was free from verbal abuse. This deficient practice was identified for 1 of 1 resident reviewed for abuse (Resident #104) and was evidenced by the following:A review of the admission Record (admission summary) indicated that Resident # 104 was admitted to the facility with the diagnoses which included but was not limited to Parkinson's disease, atrial fibrillation, depression and diabetes mellites (DM). The annual Minimum Data Set (MDS), an assessment tool used to facilitate a resident's care dated 5/29/25, indicated that Resident #104 scored a 11/15 on the Basic Interview for Mental Status (BIMS) which indicated that the resident had moderate cognitive impairment. The MDS also reflected that the resident did not exhibit any behaviors.A review of the form AAS-45 (Facility Reportable Event) dated 8/5/25, indicated that on 8/2/25 a housekeeper told Resident #104 to learn to use the toilet when the housekeeper had to clean up feces from the resident's toilet. A review of a Physical Therapist (PT) untimed statement dated 8/4/25, indicated that as the therapist was attempting to take Resident #104 for a PT session, the resident refused to go and was emotionally upset because the resident reported that a staff member humiliated them. The resident reported that a staff member had to clean the resident's toilet too often because the resident was going to the bathroom (defecating) often.A review of Resident #104's untimed statement taken 8/4/25, revealed that on 8/2/25 a housekeeper was cleaning, and the resident overheard the housekeeper saying that she had to Wipe shit off the floor and from around the toilet. I cleaned up shit this morning and now I have to do it again.A review of the emailed statement dated 8/8/25 at 12:35 PM, from the alleged perpetrator (housekeeper), reflected that the housekeeper admitted that an aide had told her that Resident #104 defecated all over the front of the toilet and it went down the front of the toilet and on the floor. The housekeeper stated, I said to [Resident #104] to come and see how you shit all over the toilet and this is so nasty, can't you shit in the toilet.The facility provided the surveyor with the full investigation and conclusion and summary related that the incident.A review of the Summary and Conclusion dated 8/6/25, indicated that the facility immediately provided the resident with 1:1 emotional support and the housekeeper was placed on administrative leave and was not permitted to return to work pending the outcome of an internal investigation.During the investigation the facility contacted the housekeeper, and the housekeeper admitted to making the comments aloud in the hall and then entered the resident's room and told the resident that he/she needed to learn how to use the toilet.As a result, the housekeeper was immediately terminated, and the facility proceeded to interview other residents in the area where Resident #104 resided. No other residents had complaints regarding any mistreatment from the housekeeper.On 9/03/2025 at 10:54 AM, the surveyor interviewed Resident #104 who stated that he/she felt that the facility did a good job and fired the housekeeper that embarrassed him/her. The resident stated that they had been doing ok and stated that they felt safe in the facility. During the interview the resident's psychologist entered the resident's room for a session with the resident.On 9/04/2025 at 11:02 AM the surveyor interviewed the Social Worker (SW) who stated that when Resident #104 reported that a housekeeper verbally abused him/her, the housekeeper was immediately terminated. The SW stated that the facility reported the incident to the Department of Health and investigated. He confirmed that the abuse was verified because the housekeeper admitted that she made derogatory comments to the resident about learning how to use the toilet by not getting feces on the toilet or on the floor. He stated that the facility provided the resident with 1:1 emotional support and the resident was being followed by a mental health specialist. The SW continued to explain that during the investigative process, the resident was interviewed, and statements were obtained from staff and other residents. He stated that he interviewed other residents that were alert and oriented and who were exposed to the housekeeper. He stated that was very important to interview other residents to ensure that it was not happening to them and to know as to what extent this was happening. The SW provide the surveyor with typed list of other residents interviewed in the immediate area of Resident #104 and according to the list, no other residents were affected.On 9/04/2025 at 11:18 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that she had reported the event to the New Jersey Department of Health (NJDOH) the same day the resident reported the incident on 8/4/25. She stated that she remembered that the SW conducted interviews with other residents on the unit or exposed to the housekeeper. The ADON stated that interviews with other residents would be important to ensure that any abuse was not happening to others and if it was, as to what extent it was occurring and to provide support and help to others that may have been affected.On 9/04/2025 at 11:31 AM, the surveyor interviewed the PT who stated that he was not sure what date Resident #104 reported that a housekeeper was verbally abusive to him/her but that no other resident reported any occurrence of abuse to him that day. He stated that he immediately reported the residents' concerns to the administration. He stated that Resident #104 did not want to attend therapy because she felt humiliated by housekeeper who made her feel bad about getting stool on the toilet and on the floor. On 9/04/2025 at 11:42 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who was also the abuse officer for the facility who stated that the verbal abuse allegation was substantiated when the housekeeper admitted that she was verbally inappropriate with the resident. He stated that the facility takes all allegation of abuse seriously and the housekeeper was terminated immediately. The LNHA stated that the SW was responsible to interview other residents on the units that the housekeeper was working on to make sure other residents were not affected. He stated that resident interview revealed that no other residents were affected by the housekeeper. The LNHA provided the surveyor with education that was conducted for all other employees in the facility from 8/15/25 until 8/20/25 regarding identification of types of abuse and on how to report abuse which contained employee signatures. On 9/05/2025 at 10:23 AM, the facility provided the surveyor with additional information and documentation that 6 (six) alert and oriented residents were interviewed by the SW regarding any abuse with staff or housekeeper while residing at the facility and each resident denied any mistreatment. The surveyor interviewed the unsampled residents and all stated that they had not experienced any mistreatment by any staff member while in the facility. The surveyor also reviewed the housekeepers file which indicated that the facility conducted a background check prior to hire in 2016 and that the housekeeper had training on the facilities abuse policy and procedures while an employee.A review of the facility policy dated 10/24/22 and titled, Abuse Prohibition indicated that the center prohibits abuse, mistreatment, neglect, misappropriation of resident/patient property and exploitation for all residents. The policy specified that verbal abuse is any use of oral, written or gestured language that willfully included disparaging and derogatory terms to patients or their families or within hearing distance, regardless of their age, ability to comprehend, or disability. NJAC 8:39-4.1(a)(5)

Based on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set death in facility tracking record in accordance with federal guidelines. This deficient practice was identified for 1 of 1 resident reviewed for resident assessment (Resident #17). This deficient practice was evidenced by:On [DATE], at 9:47 AM the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The surveyor reviewed Resident #17's electronic medical record. The record revealed that the resident expired on [DATE]. The electronic health record reflected that there was no death in facility tracking record completed for the resident's death date of [DATE]. On [DATE] at 12:30 PM, the surveyor interviewed the MDS Coordinator. The MDS Coordinator confirmed that the death in facility tracking record was not completed or transmitted for Resident #17. She stated it should have been completed and transmitted by [DATE]. A MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. NJAC 8:39-11.2

Complaints: NJ00176578, NJ00181499, NJ00184013, NJ00184932 Based on interviews, record review, and review of other pertinent facility documents on 06/04/2025 and 06/06/2025, it was determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, by failing to ensure that; a.) medications were administered according to Physician orders (POs), b.) bloodwork was obtained and faxed according to POs, and c.) Physicians were notified that medications were not administered or available. This deficient practice was identified for 1 out of 3 residents reviewed for quality of care (Resident #5). This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Review of Resident #5's undated admission RECORD revealed that Resident #5 was admitted to the facility with diagnosis that included but were not limited to acute myeloblastic leukemia (AML) (an aggressive cancer of the blood and bone marrow), not having achieved remission; anemia, unspecified; post-traumatic stress disorder; muscle weakness (unspecified); chronic kidney disease; and difficulty walking, not elsewhere classified. Review of Resident #5's Minimum Data Set (MDS), an assessment tool dated 07/04/2024, was conducted. The MDS revealed that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated that the resident had severely impaired cognition. Review of Resident#5's Medication Review Report (MRR), was conducted. The MRR revealed POs that included but were not limited to: Epoetin Alfa Injection Solution (a medication used to treat anemia by helping the body produce red blood cells) 1000 UNIT/ML (milliliter). Inject 2 ml subcutaneously one time a day every 7 days for anemia. HOLD RETACRIT (another name for epoetin alfa) IF HGB (hemoglobin) EXCEEDS 10. The order start date was 06/30/2024. Venclexta (a medication used in combination with other medications to treat AML) Oral Tablet 100 MG. Give 1 tablet by mouth once a day, 14 days on and 14 days off, for AML. The order start date was 07/16/2024 CBC (a blood test that measures the number and size of the different cells in the blood), and CMP (a blood test that aims to evaluate the function of essential organs in the body) every Monday and Thursday. The order start date was 07/10/2024. Fax lab results to Resident #5's Oncologist on evening shift every Monday and Thursday. The order start date was 07/11/2024. Resident #5's Medication Administration Records (MARs) for June, July, and August 2024 were reviewed. The MAR revealed no documentation for the 08/05/2024 dose of Epoetin Alfa Injection Solution. The MAR revealed that the code NN was entered for the following medication doses and orders: Epoetin Alfa Injection Solution on: 06/30/2024, 07/07/2024, and 07/14/2024. Venclexta Oral Tablet on: 07/16/2024, and 08/21/2024. Fax CBC and CMP results to Resident #5's Oncologist on: 08/19/2024. Review of the Chart Codes/ Follow Up Codes section of the MAR revealed that the code NN indicated No/See Nurse Notes. A review of Resident #5's progress notes (PNs) was conducted. An eMAR (electronic medication administration record) PN written by LPN #1, effective 06/30/2024 at 8:50 P.M., revealed that Epoetin Alfa injection solution was on order. An eMAR PN written by LPN #2 effective 07/07/2024 at 8:13 P.M., revealed that Epoetin Alfa injection solution was on order. An eMAR PN written by LPN #2 effective 07/14/2024 at 8:46 P.M., revealed that Epoetin Alfa injection solution was on order. An eMAR PN written by LPN #2 effective 07/16/2024 at 8:30 A.M., revealed that Venclexta oral tablet was on order. An eMAR PN written by LPN #2 effective 08/21/2024 at 9:00 A.M., revealed, [family member] bringing in due to comes from oncology pharmacy and it is shipped to her home. when she arrives will administer. Review of Resident #5's PN revealed no documentation that the aforementioned medications were administered. Resident #5's PNs revealed no documentation that the resident's physician was notified that the medication doses were not available and not given. An eMAR PN written by LPN #3 effective 08/19/2024 at 10:49 P.M., revealed that lab results were not available. Review of Resident #5's PN revealed no documentation that the aforementioned lab test results were obtained or faxed. Resident #5's PNs revealed no documentation that the resident's physician was notified that the lab test results were not available or faxed to Resident #5's Oncologist. Further review of Resident #5's PNs revealed a Lab Result Note written by Nurse Practitioner (NP)#1, dated 07/12/2024 at 11:03 P.M. The note indicated that Resident #5's Oncologist was notified of an abnormal bloodwork result and transfusion was discussed. The note further revealed Pt [patient] also get Epo [Epoetin Alfa] in center. A follow-up note dated 08/08/2024 at 3:57 P.M., written by NP #1 was reviewed. The follow-up note revealed under the Assessment & Plan section, pt gets epo inj in center weekly. and under the Health Concerns section, Pt is on Epo weekly in center. An interview was conducted with Licensed Practical Nurse (LPN) #2 on 06/06/2025 at 10:18 A.M. LPN #2 stated that the process if ordered medications were not available was to follow up with the pharmacy, notify the patient and their family, and notify the doctor. LPN #2 stated that if medications were not given the reason would be documented in the electronic medical record. LPN #2 stated that if medications were not given the doctor was notified and the notification was documented in the electronic medical record (EMR). During the same interview LPN #2 stated that when she documented on order in the PN it meant that the medication was not given. LPN #2 further stated that the pharmacy should have been called and physician notified in these instances. An interview was conducted with LPN #1 on 06/06/2025 at 11:19 A.M. LPN #1 stated that the process if ordered medications were not available was to notify the resident's doctor or use the facility's on-call service to notify a doctor. LPN #2 stated that if a medication was not available sometimes a doctor would decide to order a different medication. LPN #1 stated that if a medication was not given, she would document that in the EMR. LPN #1 stated that when she documented, on order, in the PN it meant that delivery by the pharmacy was scheduled. LPN #1 further stated that when the medication arrived and was given, the administration would have been documented in the EMR. LPN #1 stated that all documentation should have been completed by the end of the shift. An interview was conducted with Nurse Practitioner (NP) #1 on 06/06/2025 at 11:36 A.M. NP #1 stated that Epoetin Alfa was important for anemia treatment because it helped with hemoglobin levels and red blood cell production. NP#1 stated that what when she documented in center, it meant, at this facility. NP#1 further explained that if Epoetin Alfa were unavailable or not administered, she would have expected to be notified so that adjustments could have been made. An interview was conducted with the Director of Nursing on 06/06/2025 at 12:14 P.M. The DON stated that it was the expectation a resident's doctor was notified if an ordered medication was not available. The DON stated that the assigned nurse or Unit Manager were responsible for making the notification. The DON stated that the notification should have been documented in the MAR or PN. The DON stated that it was the assigned nurse's responsibility to ensure that labs were completed as ordered. The DON stated that if something was not documented in the medical record, it was not done. The DON further stated that the expectation was that all documentation was completed before the end of that shift. During a follow-up interview on 06/06/2025 at 1:19 P.M., the DON confirmed that no documentation of physician notification was available for the NN codes or blanks in the MAR on the aforementioned dates. The DON confirmed that there was no documentation that a physician was notified that Resident #5's labs were not drawn or that results were not available. The DON further stated that if lab results were not available, the expectation was that a doctor was notified, and labs were obtained as soon as possible. A follow-up telephone interview was conducted with Resident #5's physician, the facility's Medical Director (MD) on 06/10/2025 at 2:09 P.M. The MD stated that when medication were ordered it was his expectation that they were given. The MD stated that if ordered labs were not obtained he expected to have been notified. The MD stated, medications are ordered for a reason and we need to be informed if medications are not given because it can affect what we do next, it can guide our decisions. The MD further stated that Resident #5's Oncologist (ONC) should have been notified if Venclexta was not given. A telephone interview was conducted with Resident #5's ONC on 06/12/2025 at 1:50 P.M. The ONC stated that Resident #5 was treated for an aggressive form of AML. The ONC stated that Venclexta was part of the resident's chemotherapy regimen and timing of this medication was very important because it was part of a combination treatment. The ONC stated that he was not aware that Resident #5 had missed doses of Venclexta. The ONC further stated that it was his expectation that he would have been notified of missed doses of Venclexta. The facility Charge Nurse- LPN (job code NCL1) job description with a revision date of 6/16/17 was reviewed. On page 1 of 6 under POSITION SUMMARY, the job description revealed, [ .] The Charge Nurse- LPN ensures the delivery of efficient and effective nursing care while achieving positive clinical outcomes and patient/family satisfaction. Page 2 of 6 of the job description document revealed under Clinical Leadership, 2.11 Ensures that Physician Orders are followed as prescribed; [ .] 2.13 Ensures that patient's attending physician and family or responsible party are promptly notified of any significant change in the patient's health condition; The facility policy NSG115 Physician/Advanced Practice Provider (APP) Notification, with a revision date of 12/16/2024 was reviewed. The policy revealed on page 1 of 2 under POLICY, Upon identification of a patient who has a change in condition, abnormal laboratory values, or abnormal diagnostic, a licensed nurse will: [.] Collect pertinent patient information (e.g., age, diagnoses, .labs, recent changes in medications, [ . ] etc.), Report to physician/advanced practice provider (APP). If unable to contact attending physician/APP, the Medical Director will be contacted. Page 1 of 2 of the policy revealed under PURPOSE, To support effective communication and notification of physicians/APPs. N.J.A.C. : 8:39-27.1 (a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to: a) promptly record the removal of a controlled drug from inventory b) maintain accurate accountability of controlled substances within the medication administration carts c) maintain accurate accountability of all controlled medications within the automated medication dispensing system d) accurately document and complete DEA (Drug Enforcement Agency)-222 forms. This deficient practice was identified in 2 of 4 medication carts on 2 of 3 nursing units and for 12 of 12 DEA-22 forms reviewed. This deficient practice was evidenced by the following: 1. On [DATE] at 12:14 PM, the surveyor inspected the Low Hall Garden Unit medication cart with Registered Nurse (RN) #1. When the surveyor requested to inspect the controlled medications RN #1 stated, The count was going to be off (not accurate count) with the Oxycodone (a controlled medication used to treat moderate to severe pain) 5 milligram (mg) immediate release tablets. When the surveyor asked why, RN #1 stated that she felt nervous after she was observed during the medication pass by another surveyor earlier that morning and forgot to sign it out when the medication was removed from the medication cart at approximately 10:30 AM. The surveyor reviewed the declining inventory sheet (DIS) that was issued to Resident #523 and indicated that 24 tablets of Oxycodone Immediate Release 5 mg tablets remained, when only 23 tablets actually remained. RN #1 stated that she knew that she was supposed to sign the medication at the time that it was removed from the medication cart and prepared for administration. On [DATE] at 12:42 PM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM) #3 who stated a controlled medication such as Oxycodone should be signed out at the time of administration. RN/UM #3 stated that if a discrepancy were noted at shift change, it would be caught and addressed at that time. Review of Resident #523's active orders revealed an order dated [DATE], for Oxycodone HCL (hydrochloride) oral tablet 5 mg give one tablet by mouth two times a day for chronic generalized pain. Review of the resident's Medication Administration Record revealed that RN #1 documented that she administered the dosage of Oxycodone HCL oral tablet 5 mg to the resident on [DATE] at 9:00 AM. On [DATE] at 12:05 PM, the surveyor obtained a copy of Resident #523's DIS for Oxycodone Immediate Release 5 mg tablet and noted that on [DATE] at 12:00 PM, RN #1 signed the resident's 9 AM scheduled dose of Oxycodone Immediate Release 5 mg tablet as administered, rather than at 10:30 AM, as RN #1 previously stated at the time of the initial observation on [DATE] at 12:14 PM. On [DATE] at 12:38 PM, the surveyor interviewed the Director of Nursing (DON) who stated that when a controlled medication was pulled from the medication cart it must be signed for right away because it was a counted process and may cause the count to be off. DON further stated that if the resident stated that he/she had not received the medication, than the process could be ruined at that time. 2. On [DATE] at 1:02 PM, the surveyor inspected Post Acute Unit (PACU) medication cart #3 with LPN #2. The surveyor reviewed the Shift Count form with LPN #2 who stated that the outgoing nurse must have forgotten to sign the form in the space allotted for Nurse's Signature Going Off Duty this morning. LPN #2 stated that both nurses were required to sign the shift count to indicate that they were both in agreement for the amount of controlled medications that remained in the cart at the time of cart transfer for accountability purposes. LPN #2 stated that if one person did not sign, and the count was wrong, then the person who signed took more responsibility as they failed to ensure the other person signed and agreed upon the count. On [DATE] at 1:33 PM, the surveyor interviewed RN/UM #1 who stated that nurses must sign out on the Shift Count form to ensure that the controlled medication count was right at shift change. RN/UM #1 stated that she checked the book monthly to ensure compliance. RN/UM #1 stated, The oncoming nurse should not accept the medication cart from the outgoing nurse if she did not sign the Shift Count sheet because it was sloppy. RN/UM #1 further stated, The narcotic (controlled substance) count could be wrong, and you know the importance of narcotics. On [DATE] at 1:33 PM, the surveyor interviewed the DON who stated that the oncoming nurse and outgoing nurse were supposed to sign that they received the medication cart in good faith, narcotics were checked, and they were taking the cart and everything was good. DON stated there would be a write up if a shift to shift were not done. DON further stated that they should sign every time a narcotic count was done. 3. On [DATE] at 10:50 AM, the surveyor inspected the Post-Acute Unit (PACU) medication room and the automated medication dispensing system with RN/UM #1 and Licensed Practical Nurse (LPN) #3. RN/UM #1 stated that the night shift and morning nurse counted the controlled medications within the automated medication dispensing system daily and signed the Shift Count book when completed. The surveyor reviewed the book and noted that the book was not routinely signed to indicate that the count was completed daily as described by RN/UM #1. The surveyor observed that the Shift Count was completed on the following dates: [DATE]: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. February 2024: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. [DATE]: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. [DATE]: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. When interviewed at that time, RN/UM #1 stated that the automated medication system Shift Count was reviewed by the Unit Manager who was responsible to ensure that the controlled medication count was completed. RN/UM #1 stated if the Shift Count were not signed, then the count was not done. RN/UM #1 stated that the purpose of the count was to ensure that the medications were in sufficient quantity, were not expired and the count was right to prevent diversion. On [DATE] at 12:38 PM, the DON stated that the automated dispensing medication system count was done every morning by ,d+[DATE] nurse that she specifically assigned to do the count on the first cart, with the ,d+[DATE] nurse going off on the first cart. DON stated that there were some newly hired nurses who may have missed the education related to the Shift Count. 4. On [DATE] at 12:38 PM, the surveyor interviewed the DON who stated that she worked at the facility for five years. The surveyor reviewed the DEA-222 forms with the DON and questioned why 12 out of 12 forms reviewed did not have Part 5: To be filled in by purchaser and indicated the number of controlled medications received and the date received from the supplier/pharmacy. DON stated that she was not trained to fill in the amount received and copied the previous DON's method of completion. On [DATE] at 10:31 AM, the surveyor interviewed the Pharmacist in Charge (PIC) who stated that on the back of the DEA-222 form it says Part 5 to be filled in on the copy of the original form, and they should keep a copy. On [DATE] at 10:30 AM, in the presence of the survey team, the Administrator was informed that the DEA-222 forms reviewed failed to have Part 5 filled in by the purchaser as required. Review of the Instructions for DEA Form 222 that were available on the back of the form were reviewed and revealed the following: .part 5. Controlled Substance Receipt: 1. The purchaser fills out this section on its copy of the original order form. 2. Enter the number of packages furnished on each line item and the date shipped . Review of the facility policy, 6.0 General Dose Preparation and Medication Administration (Revision Date [DATE]) revealed the following: .Administer medications within timeframes specified by Facility policy or manufacturer's information Document the administration of controlled substances in accordance with Applicable Law; . Review of the facility policy, 5.4 Inventory Control of Controlled Substances (Revision Date [DATE]) revealed the following: .Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion (used for purposes not intended by prescriber) at the change of each shift or at least once daily and document the results on a Controlled Substance Count Verification/Shift Count Sheet. Review of the facility policy, 5.5 Routine Reconciliation of Controlled Substances (Effective [DATE]) Facility should routinely reconcile controlled substance emergency medications in .Omnicells (automated medication dispensing system) .and comparing the count to the number of emergency doses supplied by the pharmacy to the number of recorded doses removed by facility staff from controlled substance emergency supply . Review of the facility policy, NSG 300 Controlled Drugs: Management of (Revision Date: [DATE]) revealed the following: .Ongoing inventory: A complete count of all Schedule II-IV controlled substances is required at change of shifts per state regulation or at any time in which narcotic keys are surrendered from one licensed nursing staff to another. The count must be performed by two licensed nurses and/or authorized nursing personnel, per state regulations . NJAC 8:,d+[DATE].7(c)

Based on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to notify the resident and or resident representative in writing of the reason for transfer or discharge to the hospital for 1 of 3 residents (Resident #108) reviewed for hospitalization . This deficient practice was evidenced by the following: During the initial tour of the facility on 04/24/24 at 11:08 AM, the surveyor observed Resident #108 lying in bed awake. The resident was unable to be interviewed at that time due to a language barrier. Review of Resident #108's Admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: age-related debility, muscle wasting and atrophy (waste away, unspecified site), and obstructive and reflux uropathy (disorder of the urinary tract that occurs due to blocked urinary flow). Review of Resident #108's Progress Notes (PN) revealed a PN dated 03/26/24 at 01:05 AM, Follow-up care for abnormal labs. Vitals taken BP-(blood pressure) 132/58, P-103, RR (respirations, breathing) 17, T-(temperature) 97.1 (tympanic, temperature taken by inserting thermometer in the ear), SpO2-(pulse oximetry, probe placed on finger to obtain percentage of oxygen in the blood) 99% on room air. Skin flush. Slow to react to care. Send to .hospital at 12:52 am via stretcher x 2 assist. Call placed to Son .and left a message. There was no documented evidence that either the resident or responsible party were provided with written notification that the resident was transferred to the hospital in the resident's electronic health record (EHR). On 04/29/24 at 11:23 AM, the surveyor interviewed the Social Services Director (SSD) who stated that she had worked at the facility for [AGE] years. SSD stated she was responsible to notify the Ombudsman (an appointed official who investigates individual complaints) when a resident was hospitalized and nursing notified both the resident and their family with written notice on their way out of the facility. On 04/30/24 at 09:55 AM, the surveyor interviewed the Director of Nursing (DON)who stated that nursing was responsible to phone both the resident, family and physician and document the details of hospital transfer in the Progress Notes. DON stated that there was no written documentation provided to the resident or family upon hospital transfer from the facility. On 04/30/24 at 10:30 AM, The DON provided the surveyor with a policy related to Discharge and Transfer. She stated that the nurses had not been notifying the resident or representative in writing prior to discharge or of bed hold. DON stated the resident's were sick when they were leaving and the families sometimes got mad. Review of the facility policy, Discharge and Transfer (Revision Date 11/15/22) revealed the following: .A Center must immediately inform the patient/patient representative, consult with the patient's physician, and notify consistent with below when there is a decision to transfer or discharge the patient from the Center. The patient and patient representative must be notified in writing prior to the transfer or discharge and in a language and manner they understand . NJAC 8:39-4.1(a) 31

Based on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to complete a significant change assessment within 14 days after a resident elected hospice services using the Resident Assessment Instrument (RAI) process. This deficient practice was identified for 1 of 2 residents (Resident #24) reviewed for hospice and end of life care. This deficient practice was evidenced by the following: On 04/24/24 at 9:48 AM during the initial tour of the facility, the surveyor observed Resident #24 lying in bed asleep. The resident was accompanied by the hospice aide who provided personal care to the resident at the time of the observation. Review of Resident #24's Admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included, but were not limited to: Alzheimer's disease. Review of the resident's Order Summary Report revealed an order dated 11/01/23, Hospice Eval (evaluation) and Tx (treat). Review of Resident #24's Care Plan revealed an entry dated 11/3/23, with a Focus of Hospice start date: 11/03/23. Hospice care due to end stage of Senile Degeneration (Dementia) Review of Resident #24's Minimum Data Set (MDS), an assessment tool, revealed a Significant Change in Status assessment with an Assessment Reference Date (ARD) of 11/16/23. Further review of the assessment revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated that the resident was severely cognitively impaired. Review of Section O-Special Treatments, Procedures and Programs revealed under subsection K 1., that the resident received Hospice Care while a resident. Further review of the assessment on line Z0500 under Signature of RN (Registered Nurse) Assessment Coordinator Verifying Assessment Completion was signed as completed on 01/04/24. Further review of the assessment revealed that the Certified Clinical Reimbursement Coordinator (CCRC) RN also documented that she completed Section O on 1/4/24, which indicated that the resident received Hospice Care. On 04/29/24 at 11:06 AM, the surveyor interviewed the CCRC who stated that she worked at the facility since February of 2023. CCRC stated that Resident #24's Significant Change MDS Assessment was initiated on 11/16/23, but was not completed until 01/04/24. CCRC stated that the Significant Change Assessment should have been initiated within 14 days of when the resident entered into hospice services. CCRC further stated that there could have been a delay, but she was not able to recall why the assessment was not completed until 01/04/24, 49 days later. CCRC stated that the assessment was accepted by CMS (Centers for Medicare and Medicaid Services) on 01/08/24. CCRC further explained that she worked alone in the building after her co-worker retired in October 2023, and that was why the assessment was completed late, and not within 14 days as required. On 05/01/24 at 10:11 AM, the surveyor interviewed the Director of Nursing (DON) who stated that a Significant Change MDS Assessment should have been entered upon the initial hospice admitted . DON stated that from 11/16/23 through 01/04/24, it was delayed. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 October 2023, a Significant Change in Status MDS must be completed by the 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days). Review of the facility policy, OPS 183 MDS Remote Completion (Revision Date 12/27/21) revealed the following: .Centers will also follow the RAI Manual Instructions for completing the assessment process. .Purpose: To ensure compliance with the RAI process and timely completion of the MDS. NJAC 8:39-11.2(i)

Based on observations, interview, record review, and pertinent facility documents it was determined that the facility failed to provide appropriate treatment and care, based upon current standards of practice and the resident's comprehensive care plan specifically not securing a urinary catheter drainage bag properly resulting in the bag making contact with the floor. The deficient practice was identified for 1 of 3 (Resident # 15) investigated for Urinary Catheter. The deficient practice was evidenced by the following: A review of Resident # 15's Admission Minimum Data Set (MDS; an assessment tool) dated 04/08/2024 revealed that he/she had an indwelling catheter (tube inserted into the bladder to assist in the flow of urine). A review of Resident # 15's Electronic Medical Record (EMR) revealed under Med Diag that he/she was diagnosed with but not limited to Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms (needing to urinate frequently (during the day and night), a weak urine stream, and leaking or dribbling of urine) and Retention of Urine. A review of Resident # 15's EMR revealed under, Orders to, Empty catheter drainage bag at least once every eight hours to when it becomes 1/2 to 2/3 full every 8 hours. The order revealed a start date of 04/02/2024. A review of Resident # 15's Care Plan located in the EMR revealed a focus, [Resident # 15] requires indwelling foley catheter due to obstructive uropathy. The focus was created on 04/02/2024. The focus revealed an intervention that revealed, Record output and Keep catheter off floor. Both interventions had an initiated date of 04/02/2024. A review of Resident # 15'2 Treatment Administration Record (TAR) located in the EMR revealed the order to Empty catheter drainage bag at least once every eight hours to when it becomes 1/2 to 2/3 full every 8 hours. The TAR revealed the following dates and times were blank: 4/3 - 1400 (2:00 PM) blank 4/4 - 0600 (6:00 AM) blank 4/11 - 1400 (2:00 PM) blank 4/12 - 0600 (6:00 AM) blank 4/14 - 0600 (6:00 AM) blank 4/15 - 0600 (6:00 AM) blank 4/17 - 0600 (6:00 AM) blank, 2200 (10:00 PM) blank 4/18 - 0600 (6:00 AM) blank 4/19 - 1400 (2:00 PM) blank, 2200 (10:00 PM) blank 4/22 - 1400 (2:00 PM) blank 4/24 - 1400 (2:00 PM) blank 4/26 - 0600 (6:00 AM) blank, 2200 (10:00 PM) blank 4/29 - 0600 (6:00 AM) blank On 04/24/2024 at 10:31 AM during the initial tour of the facility, the surveyor observed Resident # 15 in their room. At that time, the surveyor observed the urinary catheter drainage bag in contact with the wheels of the bed. On 04/26/2024 at 10:07 AM, the surveyor observed Resident # 15 in their room. At that time, the surveyor observed the urinary catheter drainage bag in contact with the floor. The urinary catheter drainage bag was not secured too the bed frame. On 04/29/2024 at 09:07 AM, the surveyor observed Resident # 15 in their room. At that time, the surveyor observed the urinary catheter drainage bag in contact with the floor. On 04/30/2024 at 11:11 AM during an interview with the surveyor, Certified Nurses Aide (CNA) # 1 said that when emptying the urinary catheter drainage bag, she measures and tells the nurse. CNA # 1 confirmed that the nurse documents the TAR. On the same date at 11:28 AM during an interview with the surveyor, the Unit Manager/Registered Nurse # 1 confirmed that the nurse documents in the TAR. On 05/01/2024 at 09:54 AM, the surveyor observed Resident # 15 in their room. At that time, the surveyor observed the urinary catheter drainage bag in contact with the floor. At that time, CNA # 2 was present in the room. At that time, CNA # 2 referred to Resident # 15's urinary drainage bag and stated, It's all twisted up. The surveyor asked her if it should be on the floor. CNA # 2 replied, No. On 05/01/2024 at 12:14 PM during an interview with the surveyor, the Director of Nursing (DON) replied, No when asked by the surveyor if the urinary drainage bag should be in contact with the floor. Secondly, the DON replied, Infection control when the surveyor asked why the urinary drainage bag should not be in contact with the floor. Also, the DON confirmed that nurses document urinary outputs in the TAR. Lastly, the DON replied, I know they [nurses] empty it but if it's not documented, it's not done . A review of the facility provided document titled, NSH113 Nursing Documentation revised 05/01/23 revealed under the section titled, Practice Standards that, 1. Documentation of nursing care is recorded in the medical record and is reflective of the care provided by nursing staff . A review of the facility provided document titled, Procedure: Catheter: Indwelling Urinary - Care Of revised 02/01/23 revealed, 13. Secure catheter tubing to keep the drainage bag below the level of the patient's bladder and off the floor . S 8:39-27.1 (a)

NJ Complaint #159967, #159711, #169655, #170197, Based on interview, review of the Nurse Staffing Report and other facility documentation, it was determined that the facility failed to ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by the following: On 04/29/24 at 10:30 AM, the surveyor held a Resident Council meeting with six residents in attendance. During the Resident Council meeting the surveyor asked all residents in attendance if they received showers, or assistance with showers. Four of the six residents in attendance told the surveyor that showers were not offered twice weekly (Resident #21, #84. #94, and #122). All were aware of their shower day schedule but stated they do not always receive them because of staffing issues. 1.For the week of Complaint staffing from 10/02/2022 to 10/08/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -10/02/22 had 6.5 CNAs for 111 residents on the day shift, required at least 14 CNAs. -10/03/22 had 8 CNAs for 110 residents on the day shift, required at least 14 CNAs. -10/04/22 had 7 CNAs for 110 residents on the day shift, required at least 14 CNAs. -10/05/22 had 6 CNAs for 110 residents on the day shift, required at least 14 CNAs. -10/06/22 had 10 CNAs for 110 residents on the day shift, required at least 14 CNAs. -10/07/22 had 8 CNAs for 115 residents on the day shift, required at least 14 CNAs. -10/08/22 had 10 CNAs for 115 residents on the day shift, required at least 14 CNAs. 2. For the week of Complaint staffing from 10/16/2022 to 10/22/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in CNAs to total staff on 1 of 7 evening shifts as follows: -10/16/22 had 5 CNAs for 119 residents on the day shift, required at least 15 CNAs. -10/17/22 had 7 CNAs for 119 residents on the day shift, required at least 15 CNAs. -10/17/22 had 5 CNAs to 12.5 total staff on the evening shift, required at least 6 CNAs. -10/18/22 had 8 CNAs for 119 residents on the day shift, required at least 15 CNAs. -10/19/22 had 8 CNAs for 119 residents on the day shift, required at least 15 CNAs. -10/20/22 had 9 CNAs for 120 residents on the day shift, required at least 15 CNAs. -10/21/22 had 8 CNAs for 120 residents on the day shift, required at least 15 CNAs. -10/22/22 had 10 CNAs for 120 residents on the day shift, required at least 15 CNAs. 3. For the week of Complaint staffing from 11/20/2022 to 11/26/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in CNAs to total staff on 1 of 7 evening shifts as follows: -11/20/22 had 9 CNAs for 114 residents on the day shift, required at least 14 CNAs. -11/21/22 had 7 CNAs for 113 residents on the day shift, required at least 14 CNAs. -11/22/22 had 9 CNAs for 109 residents on the day shift, required at least 14 CNAs. -11/23/22 had 9 CNAs for 109 residents on the day shift, required at least 14 CNAs. -11/23/22 had 6.5 CNAs to 14 total staff on the evening shift, required at least 7 CNAs. -11/24/22 had 8.5 CNAs to 108 residents on the day shift, required at least 13 CNAs. -11/25/22 had 6 CNAs for 107 residents on the day shift, required at least 13 CNAs. -11/26/22 had 8.5 CNAs for 107 residents on the day shift, required at least 13 CNAs. 4. For the week of Complaint staffing from 12/04/2022 to 12/10/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in CNAs to total staff on 1 of 7 evening shifts as follows: -12/04/22 had 8.5 CNAs for 113 residents on the day shift, required at least 14 CNAs. -12/05/22 had 5 CNAs for 113 residents on the day shift, required at least 14 CNAs. -12/05/22 had 6 CNAs to 14 total staff on the evening shift, required at least 7 CNAs. -12/06/22 had 11 CNAs for 113 residents on the day shift, required at least 14 CNAs. -12/07/22 had 7 CNAs for 113 residents on the day shift, required at least 14 CNAs. -12/08/22 had 9.5 CNAs for 113 residents on the day shift, required at least 14 CNAs. -12/09/22 had 8 CNAs for 112 residents on the day shift, required at least 14 CNAs. -12/10/22 had 9 CNAs for 111 residents on the day shift, required at least 14 CNAs. 5. For the week of Complaint staffing from 12/10/2023 to 12/16/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in CNAs total staff on 3 of 7 evening shifts as follows: -12/10/23 had 8.5 CNAs for 111 residents on the day shift, required at least 14 CNAs. -12/11/23 had 12.5 CNAs for 110 residents on the day shift, required at least 14 CNAs. -12/11/23 had 6 CNAs to 18 total staff on the evening shift, required at least 9 CNAs. -12/12/23 had 11 CNAs for 110 residents on the day shift, required at least 14 CNAs. -12/12/23 had 7 CNAs to 17.5 total staff on the evening shift, required at least 9 CNAs. -12/13/23 had 9.5 CNAs for 108 residents on the day shift, required at least 13 CNAs. -12/13/23 had 7 CNAs to 16 total staff on the evening shift, required at least 8 CNAs. -12/14/23 had 11 CNAs for 108 residents on the day shift, required at least 13 CNAs. -12/15/23 had 10 CNAs for 108 residents on the day shift, required at least 13 CNAs. -12/16/23 had 12.5 CNAs for 108 residents on the day shift, required at least 13 CNAs. 6. For the week of Complaint staffing from 12/31/2023 to 01/06/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in CNAs to total staff on 2 of 7 evening shifts as follows: -12/31/23 had 8 CNAs for 131 residents on the day shift, required at least 16 CNAs. -12/31/23 had 6 CNAs to 15 total staff on the evening shift, required at least 7 CNAs. -01/01/24 had 7 CNAs for 131 residents on the day shift, required at least 16 CNAs. -01/02/24 had 10 CNAs for 131 residents on the day shift, required at least 16 CNAs. -01/03/24 had 12 CNAs for 131 residents on the day shift, required at least 16 CNAs. -01/04/24 had 12 CNAs for 132 residents on the day shift, required at least 16 CNAs. -01/04/24 had 7 CNAs to 15.5 total staff on the evening shift, required at least 8 CNAs. -01/05/24 had 12 CNAs for 132 residents on the day shift, required at least 16 CNAs. -01/06/24 had 10 CNAs for 132 residents on the day shift, required at least 16 CNAs. 7. For the 2 weeks of staffing prior to survey from 04/07/2024 to 04/20/2024, the facility was deficient in CNA staffing for residents on 14 of 14 day shift, deficient in total staff for residents on 1 of 14 evening shifts, deficient in CNAs to total staff on 10 of 14 evening shifts, and deficient in total staff for residents on 1 of 14 overnight shifts as follows: -04/07/24 had 10 CNAs for 119 residents on the day shift, required at least 15 CNAs. -04/07/24 had 5 CNAs to 12 total staff on the evening shift, required at least 6 CNAs. -04/08/24 had 10 CNAs for 119 residents on the day shift, required at least 15 CNAs. -04/08/24 had 11 total staff for 119 residents on the evening shift, required at least 12 total staff. -04/08/24 had 4 CNAs to 11 total staff on the evening shift, required at least 5 CNAs. -04/09/24 had 10 CNAs for 119 residents on the day shift, required at least 15 CNAs. -04/09/24 had 4.5 CNAs to 14 total staff on the evening shift, required at least 7 CNAs. -04/10/24 had 9 CNAs for 119 residents on the day shift, required at least 15 CNAs. -04/10/24 had 4 CNAs to 13.5 total staff on the evening shift, required at least 7 CNAs. -04/11/24 had 12 CNAs for 118 residents on the day shift, required at least 15 CNAs. -04/11/24 had 5 CNAs to 12.5 total staff on the evening shift, required at least 6 CNAs. -04/12/24 had 9.5 CNAs for 116 residents on the day shift, required at least 14 CNAs. -04/13/24 had 7.5 CNAs for 116 residents on the day shift, required at least 14 CNAs. -04/13/24 had 5.5 CNAs to 15.5 total staff on the evening shift, required at least 7 CNAs. -04/14/24 had 6 CNAs for 116 residents on the day shift, required at least 14 CNAs. -04/14/24 had 4 CNAs to 13.5 total staff on the evening shift, required at least 7 CNAs. -04/15/24 had 10 CNAs for 116 residents on the day shift, required at least 14 CNAs. -04/15/24 had 5 CNAs to 14 total staff on the evening shift, required at least 7 CNAs. -04/16/24 had 9 CNAs for 116 residents on the day shift, required at least 14 CNAs. -04/16/24 had 8.5 CNAs to 17.5 total staff on the evening shift, required at least 9 CNAs. -04/17/24 had 11 CNAs for 118 residents on the day shift, required at least 15 CNAs. -04/17/24 had 5.5 CNAs to 12.5 total staff on the evening shift, required at least 6 CNAs. -04/18/24 had 11 CNAs for 118 residents on the day shift, required at least 15 CNAs. -04/19/24 had 13.5 CNAs for 118 residents on the day shift, required at least 15 CNAs. -04/20/24 had 12 CNAs for 118 residents on the day shift, required at least 15 CNAs. -04/20/24 had 7 total staff for 118 residents on the overnight shift, required at least 8 total staff. On 04/30/24 at 10:20 AM, the surveyor reviewed the policy titled, ADLs (Activities of Daily Living) with a revision date of 05/01/23. Under the section titled, Practice Standards, number five indicated that documentation of ADL care is recorded in the medical record and is reflective of the care provided by the nursing staff. ADL care will be documented in real time, as close to the time that the care was provided, and information obtained as possible. ADL care is documented every shift by the nursing assistant. On 04/30/24 at 12:10 PM, the surveyor interviewed CNA #1 (Certified Nursing Assistant) on the subacute unit. CNA#1 told the surveyor that the shower schedules were in the assignment book which included the days and shift for showers. CNA#1 said that the nurse or unit manger tells the CNA which showers were due for the day. On 05/01/24 at 11:11 AM, the surveyor interviewed CNA#4 of the Lighthouse Unit on the first floor. CNA #4 stated residents get showered twice weekly and if one shower was skipped, we would make sure the resident got the second shower later that week. On 05/01/24 at 11:21 AM, the surveyor interviewed CNA#3 on the second-floor unit at the facility. CNA#3 told surveyor that there are times when they are so short staffed that showers are not able to be completed. CNA#3 said she believes it happens on all shifts and if unable to give a shower she would offer a bed bath or a shower in the afternoon. On 05/01/24 at 11:30 AM, the surveyor reviewed the bathing task list for Resident #21 for the month of April. For the month of April, the task list was blank for the first 22 days indicating care was not rendered. The task was signed by staff for 4/23, 4/25, 4/26, and 4/29 by the CNA, indicating the resident had a bath and not a shower. The surveyor reviewed the bathing task list for Resident #94 for the month of April. The resident had received a bath six of the 30 days. It was documented that the resident received a bath and not a shower. The surveyor reviewed the bathing task list for Resident #84. The resident was scheduled for showers on Wednesday and Saturdays on day shift. For the month of April, the only shower documented as completed was on 4/20/24. The other scheduled days were left blank. The surveyor reviewed the bathing task list for Resident #122. The residents task list showed a shower schedule for Sundays and Thursdays on evening shifts. The resident was scheduled for 4/22/24, 4/25/24 and 4/29/24 and they were left blank as not completed. On 05/01/24 at 12:28 PM during an interview with the Director of Nursing (DON) regarding documentation, the DON stated, If it's not documented it's not done. On 05/01/24 at 12:32 PM, when the DON was asked about staffing numbers for the CNAs she stated, I know we are not meeting the numbers. NJAC 8:39-25.2 (a)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to use appropriate infection control practices, specifically failing to adhere to the minimum time to lather hands during hand hygiene when providing wound care. The deficient practice was observed during wound care for 1 of 2 residents (Residents # 59) investigated for Pressure Ulcer/Injury. The deficient practice was evidenced by the following: A review of Resident # 59's Quarterly Minimum Data Set (MDS; an assessment tool) dated 01/22/2024 revealed that he/she had wounds. A review of Resident # 59's Electronic Medical Record (EMR) revealed under Orders to Cleanse Right heel with wound cleanser. Pat dry. Apply hydrogel fluffed gauze. Cover with ABD, wrap with kling [gauze-style bandage] every day shift for open wound for 14 Days AND as needed. The order was initiated on 04/25/2024. A review of Resident # 59's EMR revealed under Care Plan a focus that Resident # 59 has a documented pressure ulcer to the right heel. The focus was initiated on 04/24/2024. On 04/26/2024 at 10:38 AM, the surveyor obtained permission from Resident # 59 to observe his/her wound care. The wound care was performed by Licensed Practical Nurse (LPN) # 1. At this time, LPN # 1 applied disposable gloves and proceeded to remove the old dressing from Resident # 59's right heel. After that, LPN # 1 removed the disposable gloves. The surveyor observed LPN # 1 enter the resident room bathroom leaving the door open. The surveyor observed LPN # 1 turn on the faucet, apply hand soap from the dispenser, lather her hands and rinsed them in water. During this observation, the surveyor used the clock provided on the state-issued computer to determine the amount of seconds while LPN # 1 performed hand hygiene. The total hand hygiene process was 19 seconds. At that time, LPN # 1 applied a new pair of disposable gloves. LPN # 1 then proceeded to administer the hydrogel to 4x4 inch gauze, covered that with the ABD pad followed by wrapping the heel with kling. Afterwards, LPN # 1 removed the disposable gloves. The surveyor observed LPN # 1 enter the resident room bathroom leaving the door open. The surveyor observed LPN # 1 turn on the faucet, apply hand soap from the dispenser, lather her hands and rinsed them in water. During this observation, the surveyor used the clock provided on the state-issued computer to determine the amount of seconds while LPN # 1 performed hand hygiene. The total hand hygiene lathering process was 9 seconds. At that time, LPN # 1 applied a new pair of disposable gloves. LPN # 1 then proceeded to applied tape to the kling wrap. Afterwards, LPN # 1 removed the disposable gloves. The surveyor observed LPN # 1 enter the resident room bathroom leaving the door open. The surveyor observed LPN # 1 turn on the faucet, apply hand soap from the dispenser, lather her hands and rinsed them in water. During this observation, the surveyor used the clock provided on the state-issued computer to determine the amount of seconds while LPN # 1 performed hand hygiene. The total hand hygiene lathering process was 12 seconds. On the same date at 10:46 AM during an interview with the surveyor, LPN # 1 replied, Yes when the surveyor asked if she felt like she lathered for twenty seconds. At that time, the surveyor asked LPN # 1 if the twenty seconds applied to lathering or the entire process. LPN # 1 replied, Lathering. Twenty seconds but it may take more time. On 05/01/2024 at 12:14 PM during an interview with the surveyor, the Director of Nursing replied, Twenty seconds when the surveyor asked how long should the lathering portion be during hand hygiene. A review of the facility provided policy titled, IC203 Hand Hygiene revised 05/01/23 revealed under, 2. Hand hygiene techniques: that, 2.1 To wash hands with soap and water: Wet hands with warm (not hot) water, apply soap to hands, and rub hands vigorously outside the stream of water for 20 seconds covering all surfaces of the hands and fingers . S 8:39-19.4 (a) 1

Based on record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) assessment for the pneumococcal vaccination for 1 (Resident #4) of 5 residents whose MDS assessments were reviewed. Findings included: Reference: Review of the Centers for Medicare and Medicaid Services' [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] User's Manual for Version 3.0, revised in October 2023, indicated Coding Instructions O0300A, Is the Resident's Pneumococcal Vaccination Up to Date? Code 0, no: if the resident's pneumococcal vaccination status is not up to date or cannot be determined. Proceed to item O0300B, If Pneumococcal vaccine not received, state reason. The Manual further indicated Code 2, Offered and declined: resident or responsible party/legal guardian has been informed of what is being offered and chooses not to accept the pneumococcal vaccine. A review of an Admission Record indicated the facility admitted Resident #4 on 08/14/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD) and diabetes. A review of an admission MDS, with an Assessment Reference Date (ARD) of 08/20/2023, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The pneumococcal vaccination section (Section O0300B) was coded 2 to reflect the pneumococcal vaccine was offered and declined. Review of Resident #4's immunization record revealed it lacked evidence to indicate the pneumococcal vaccine had been offered and declined. Review of a form titled Pneumococcal Vaccine Informed Consent revealed the form was signed and dated by Resident #4 on 10/05/2023 (the same date as the survey). During an interview on 10/05/2023 at 2:07 PM, the MDS Coordinator revealed she could not find any supportive documentation to show that Resident #4 was offered and declined the pneumococcal vaccine. The MDS Coordinator stated she could not recall where she retrieved the information to answer the questions in section O0300 of Resident #4's admission MDS assessment with an ARD of 08/20/2023. The Director of Nursing (DON) was interviewed on 10/05/2023 at 2:11 PM. She stated the MDS Coordinator was expected to check the medical record for vaccination consent history before answering any related MDS coding questions. The Administrator was interviewed on 10/05/2023 at 1:58 PM. He stated his expectation was for all MDS assessments to be accurate. NJAC: 8:39-11.1

Based on interview, record review, and facility policy review, the facility failed to maintain documentation of eligibility and consent to receive or refusal of the pneumococcal vaccination upon admittance into the facility for 1 (Resident #4) of 5 residents reviewed for immunizations. Findings included: Review of a facility policy titled Pneumococcal Vaccination, with a revised date of 11/15/2022, indicated, Upon admission, obtain the pneumococcal vaccination history of all patients. It further revealed 1.2 Document pneumococcal vaccination history in PointClickCare (PCC) and on the Pneumococcal Consent form under Vaccination History. 2. Based on the patient's pneumococcal vaccination history, offer (unless the vaccination is medically contraindicated, or the patient has already been vaccinated) the appropriate vaccination following the recommended schedule. A review of an Admission Record revealed the facility admitted Resident #4 on 08/14/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD) and diabetes. A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/20/2023, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Review of Resident #4's immunization record revealed it lacked evidence to indicate the pneumococcal vaccine had been offered and administered or refused. Review of a form titled Pneumococcal Vaccine Informed Consent revealed the form was signed and dated by Resident #4 on 10/05/2023 (the same date as the survey). During an interview on 10/05/2023 at 11:58 AM, Resident #4 said they were not offered the pneumococcal vaccine upon admission or prior to 10/05/2023. The interim Infection Preventionist (IP) was interviewed on 10/05/2023 at 11:35 AM. She stated Resident #4 was offered and educated about the pneumococcal vaccine upon admission, but there was not any documentation to support this other than todays consent form. The Director of Nursing (DON) was interviewed on 10/05/2023 at 1:29 PM. She stated Resident #4 should have been offered the pneumococcal vaccine upon admission, and if the resident had declined the offer, then documentation of the refusal should have been completed. The Administrator was interviewed on 10/05/2023 at 1:56 PM. He stated he expected all vaccinations to be offered upon admission, including the pneumococcal vaccine, and that all consents should be documented in the resident's medical record. NJAC 8:39-19.4 (a)(i)

Based on interview and review of facility documentation, it was determined that the facility failed to consistently offer residents HS (hour of sleep) snacks. This deficient practice was identified for 5 of 5 residents (Resident #17, #23, #68, #44, and #25) during resident council meeting and was evidenced by the following: On 03/22/22 at 11:06 AM, the Surveyor conducted resident council meeting with five residents. During that time, the Surveyor inquired about HS snacks. All five residents commented that they do not always get offered bedtime snacks and that it would depend on the staff that evening. On 03/23/22 at 8:09 AM, the second floor Licensed Practical Nurse Unit Manager (LPN UM) stated that the process would be for the evening snacks to be delivered from the kitchen about 6:45 PM to 7 PM. The LPN UM stated some snacks are assigned to certain residents and the other snacks would be offered to the rest of the residents. The LPN UM stated that the Certified Nursing Assistants (CNAs) would either document on the computer or on the Activities of Daily Living (ADL) log if the resident refused or accepted the snack and how much was consumed. On 03/23/22 at 9:15 AM, the Surveyor reviewed all residents Kardex (the CNA Care Plan to assist with resident needs), the ADL logbook from 03/01/22 through 03/22/22, for all five residents and found the documentation to be incomplete. The Surveyor reviewed the electronic documentation from 03/01/22 through 03/22/22, for HS snacks for all five residents and found the documentation to be incomplete. The documentation reflected the following: Resident #17's Kardex indicated under Eating to provide with HS yogurt, and PB and J (peanut butter and jelly), and to offer snacks. The ADL logs and electronic record combined reflected that the resident was not offered an HS snack 16 of the 22 days in March 2022. Resident #23's Kardex indicated under Eating; that the resident likes to snack between meals. The ADL logs and electronic record combined reflected that the resident was not offered an HS snack 18 of the 22 days in March 2022. Resident #25's Kardex indicated under Eating; to offer snacks. The ADL logs and electronic record combined reflected that the resident was not offered an HS snack 18 of 22 days in March 2022. Resident #44's Kardex indicated under Eating; to offer additional snacks. The ADL logs and electronic record combined reflected that the resident was not offered an HS snack 20 of 22 days in March 2022. Resident #68's Kardex indicated under Eating; to offer additional snacks. The ADL logs and electronic record combined reflected that the resident was not offered an HS snack 21 of 22 days in March 2022. On 03/23/22 at 11:34 AM, a CNA stated her normal shift was 11 AM to 11 PM. She stated the process was that the snacks would be delivered from come the kitchen and that the CNAs should start handing them out to the residents. She further stated the CNAs would document in the computer or the ADL log if a resident refused or accepted the snack and how much was consumed On 03/23/22 at 1:28 PM, the Director of Nursing (DON) provided the surveyor with the task accountability sheets for the five residents who attended resident council. The DON and the Surveyor reviewed the sheets and noted many blanks on all five residents. The DON stated that would indicate that the CNAs did not offer the snacks, and that the task was not done. A review of the facility provided, Meal Service indicated that breakfast starts at 7:15 AM, lunch starts at 11:50 AM, dinner starts at 4:30 PM and snacks between meals at 10 AM, 2 PM, and nightly before bedtime. A review of the facility provided policy and procedure, Snacks, Nourishments, Supplements, and Pantry Stock' revised 06/15/18, included but was not limited to the following information. Policy snacks, nourishments, supplements, and pantry stock are available to complement meal service .Definitions Snack evening snack is planned as part of the menu. Purpose to provide an evening snack for all patients/residents. Process 1. Snacks 1.4 nursing or designated staff offer an evening snack to every patient/resident. 5.2 completed logs are used to assist the facility in problem analysis and resolution. This concern was presented to the facility administration on 03/25/22. The facility had no additional information to provide. NJAC 8:39-17.4(b)

Based on observation, interview and document review, it was determined that the facility failed to maintain the kitchen in a clean and sanitary manner to limit the spread of infection and potential food borne illness by failing to ensure: a.) the environment and kitchen equipment was maintained in a manner to limit the potential for microbial growth and to prevent physical contaminants from entering the food, b.) staff practiced appropriate hand hygiene and restrained hair appropriately, c.) food items were maintained in a manner to ensure they were not used past their use by date, and d.) a process was in place to ensure bottled water was maintained in a manner to ensure the water was not used by a use by date. The deficient practice was evidenced by the following: On 03/17/22 at from 9:32 AM to 11:30 AM, the Surveyor conducted an initial tour of the kitchen with the Food Service Director (FSD), and observed the following: 1. The refrigerated walk-in unit had a dark spot affixed to the interior of the wall by the door, and what appeared as greenish dark stained areas throughout the interior of the walls of the walk-in unit. The FSD stated the spot was a little dirt spot, and the interior was cleaned once per week and that spot was probably missed. A block of opened Swiss cheese was located on a shelf and was wrapped in plastic. The cheese did not contain a use by date. 2. A dietary worker (DW #1) stacked insulated bases on top of one another at the tray line area. The bases appeared visibly wet inside. Upon interview, the DW #1 stated stated that the bases were dry, and she continued to stack them on top of one another. The Surveyor then observed the bases with the FSD, and the Surveyor inquired to the FSD if the the lids were supposed to be dry. The FSD stated they were supposed to be dry and that they were wet nesting. There were 83 insulated bases stacked that were visibly wet inside, and one base had visible debris caked on it. The FSD stated they if the bases were wet, that they won't heat up because the system was a heat on demand system (an insulated base would be inserted into a machine which would assist with maintenance of the food temperature upon meal transport). The Surveyor observed 34/34 insulated lids that were stacked, and visibly wet inside. The FSD stated that the lids/bases were supposed to be stacked sideways to dry them and the staff did not do that. 3. Two ceiling grates and a ceiling heat/air conditioner vent above the tray line area had visible dark dust like debris in the vents and on the ceiling tile adjacent to the vents. The FSD observed the ceiling and stated that maintenance usually cleaned the grate once per month and she was not sure if it was scheduled to be completed. The FSD observed the vents and stated maybe from heat and that it was not okay, absolutely not, the dust could fall onto the food. The FSD stated she was able to contact maintenance if something needed to be cleaned. 4. Two stainless steel shelves affixed to the front of the tray line were visibly soiled with various colored debris underneath the shelves. The FSD stated the shelves were used during the meal service to hold food items. The FSD observed the debris and stated the staff usually wiped the shelves down. The Surveyor inquired as to what the debris was and the FSD stated food splats and responded probably not when the surveyor inquired if the underneath of the shelves was cleaned. The FSD stated it should be cleaned daily. 5. A can opener was affixed to a metal table in the kitchen. The blade appeared visibly worn, and a copious amount metal shavings were visible at the blade area. The Surveyor inquired to the FSD about the can opener blade and the FSD stated the can opener blade was worn. The Surveyor inquired as if it was okay to use the can opener in that condition and she stated it was not okay. The FSD confirmed that the can opener was used that morning to open cans of applesauce, and stated the metal shavings could fall into the food. The plastic type insert that contained the can opener appeared soiled. The FSD removed the insert, and the Surveyor observed a dark sticky in appearance substance, and the FSD stated it's dirty and that the insert was hard to remove. The FSD stated it was probably not cleaned last night. The Surveyor requested a cleaning log from the FSD. The FSD directed the Surveyor to a bulleting board that had A Daily Cleaning Assignment (one sheet for each day of the week) affixed to a bulletin board. The Daily Cleaning Assignment list dated 3/16 revealed the Bottom of the Prep Table number 1 and 2 (Bins included and legs) was signed off and initialed as completed. The underneath of the shelves, and the can opener and base was not listed on The Daily Cleaning Assignment dated 3/16. 6. A steel preparation table had a utensil rack over the table with visible dust like debris affixed to it. The surveyor inquired to the FSD regarding the debris and she stated, it shouldn't be there. The FSD stated she was responsible to monitor the kitchen environment for cleanliness. 7. A reach-in refrigeration unit, #17, contained a 1/2 empty 12 ounce soda bottle. The FSD stated the items were from a staff member, and that personal items should not be kept in that refrigerator. The gasket to the reach-in refrigeration unit was heavily soiled with a dark substance and was ripped. The Surveyor inquired if it had been cleaned, and if the ripped gasket was acceptable. The FSD acknowledged the ripped gasket and stated that the refrigeration unit can loose temperature if the gasket was ripped and it was not okay. She stated the gasket had also not been cleaned. 8. At 10:42 AM, the Surveyor interviewed the Assistant Food Service Director (AFSD), in the presence of the FSD about the observations of the can opener and the process for cleaning it. The AFSD stated that she had used the can opener yesterday, and she had observed shavings on the lid of the tomato sauce can. She stated she had worked at the facility for twenty years and the Surveyor inquired if she had received education about the can opener, and shavings from the can opener. The AFSD stated no. The Surveyor inquired as to the process for cleaning the can opener insert and the AFSD stated it was pretty stuck and it was not always pulled out. The Surveyor inquired to the FSD regarding what should have been done when the AFSD identified there were metal shavings on the can opener and also on the lid of the can. The FSD stated when the can opener blade was dull there was a potential for shavings. The FSD stated I don't have any recent training on the can opener. 9. A stack of black meal trays were located at the beginning of the tray line. The FSD stated the trays were clean. There were 96 wet nested trays, 6 trays with debris on them and 8 trays that were visibly chipped and worn. The FSD confirmed the surveyors observations and stated the chipped trays should not be used because the fiberglass from the trays could potentially get into the food. 10. There were five large cutting boards stacked by the food preparation table. A yellow, two white, one red and one blue cutting board were observed with deep gauges and appeared worn, discolored with imbedded debris. The AFSD and FSD were present and the AFSD stated that food can get stuck and that it was wear and tear. The FSD stated that the 5/5 cutting boards shouldn't be used. 11. A large blender was stored upright on a preparation table. The gasket was soiled with debris. The FSD stated the gasket was not clean. On 03/18/22 at 11:31 AM, the Surveyor conducted a follow-up kitchen observation during the meal service preparation, and the observed the following: 12. A cook (Cook #1) was observed placing frozen dinner rolls on a tray. The cook was wearing a surgical mask on his face, and had facial hair that was visible and not restrained. 13. At 11:38 AM the FSD was observed placing milk on resident meal trays after she exited the tray line to retrieve the milk, adjusted her personal clothing and then touched various tray items without first performing hand hygiene. 14. At 11:40 AM, a staff member was observed in the kitchen at the end of the tray line and had a facial type restraint that did not fully cover the sides of his protruding facial hair. The staff identified himself as a Regional Manager (RM). The surveyor inquired to RM what he was wearing on his face and he stated it was a surgical mask and a beard guard-beard restraint was over it. The Surveyor inquired to the RM if all of the beard should be covered. The RM stated as much as can be for the beard, not the sides. At 12:22 PM, the Surveyor interviewed the FSD regarding if a surgical mask was acceptable to use as a facial hair restraint. The FSD stated no, and the Surveyor inquired to the FSD regarding the policy regarding how much facial hair should be covered, and if it was only for hair at a certain length. The FSD stated she was unsure. 15. At 11:48 AM, the RM was observed assisting moving items at the tray line, while the tray line was in progress, and the RM had visible facial hair that was exposed and was not covered by the beard restraint. 16. At 11:49 AM, Cook #1 was observed wearing gloves as he entered the kitchen with a pan of oranges. He then proceeded to wash the oranges and cut the oranges. Upon Surveyor inquiry, Cook #1 stated the oranges were to be used to replace the grapes that were on the menu, and he proceeded to provide the oranges to the tray line, and then brought the soiled pan and a strainer back to the dirty area in the kitchen. The Cook #1 returned to the tray line wearing gloves, removed the gloves and put on a new pair of gloves, without first washing his hands. The Cook #1 then proceeded to cut and serve a grilled cheese sandwich on a resident's meal plate. 17. At 11:57 AM, the FSD was observed on the tray line touching resident meal trays. The phone rang and the FSD exited the tray line to answer the phone opposite of the tray line, then returned to preparing resident meal trays on the tray line without performing hand hygiene. 18. At 12:27 PM, the Surveyor interviewed the FSD regarding when hand washing should be performed. The FSD stated when tasks were changed, or when someone touched their hair of face, that the hands should be washed after. 19. A Dietary Staff (Dietary Staff #2) was observed working in the kitchen and on the tray line with hair protruding from his hair restraint. The surveyor informed the FSD of the observation and the FSD stated that she had bigger hair nets for him and that sometimes he wore them. The FSD proceeded to show the Surveyor the larger sized hair net. 20. The dry food storage room contained a dented #10 can of beans on a rack. The FSD stated the dented can needs to be sent back, because they can get sick from dented cans. The FSD confirmed the can was dented. 21. The dry food storage room contained seven loaves of Texas toast bread, imprinted with a best if used by date of March 16. There was no other use by date located on the loaves and the FSD stated that the bread was used by the best by date. 22. The Surveyor interviewed the FSD regarding the observation made with the Cook # 1 preparing the oranges, without washing his hands between tasks. The FSD stated the Cook #1 should have washed his hands between clean and dirty. The Surveyor also interviewed the FSD regarding the observation when the FSD exited the tray line to answer the phone and returned to the tray line without washing her hands. The FSD stated I probably should have washed my hands. 23. On 03/22/22 at 12:04 PM, the Surveyor observed the tray-line in progress. The AFSD was observed cutting a sandwich on a very worn, discolored white cutting board that had deep gauges in it that was affixed to the tray line, and then placed the sandwich on a resident meal tray. 24. On 03/23/22 at 9:37 AM, the Surveyor accompanied the Maintenance Director (MD) and observed the storage of the on-site emergency water supply. The MD stated the 5 gallon water containers were stored in various areas and he had 128, 5 gallon water containers. The MD stated he purchased them, inventoried them and that the water would be used for drinking, food preparation, bathing and to flush toilets. An area for water storage was observed with 33, 5 gallon water containers that were stored under the stairwell #1, and an additional water supply was located under a rear stairwell. The 5 gallon water containers stored under the stairwell were observed to be stored directly on the floor. The Surveyor could not ascertain how many bottles were located under the rear stairwell. There water was not stamped or identified with an expiration date. The Surveyor inquired to the MD regarding the process and expiration for the water. The MD stated he did not have a sticker or label on the water for an expiration date, and stated he thought that he had the bottles for about four years. The MD stated that he checked the inventory, but not the expiration. The Surveyor observed the third location for the water which was in a trailer outside the rear of the facility. The trailer was located in the rear of the facility parking lot. There were 51 bottles of water stored in the trailer, there was various debris and dust observed around the bottles and cob-webs observed on the bottles. The bottles were also observed to be stored with various types of mechanical equipment, and 3 large cardboard boxes labeled with a red biohazard (containing blood and regulated medical waste) emblem affixed to the box, and labeled Regulated Medical Waste. The MD then, proceeded to bring a 5 gallon bottle of water and place it on the floor of the trailer, directly next to the hazardous waste. The MD showed the Surveyor the stamp on the 5 gallon bottle of water that was dated 3/31/16 on bottle. The MD stated I guess it has been longer. The Surveyor requested a policy/ information regarding the expiration of the water. At 11:22 AM the MD stated the date on the bottle was the best use date and he would look for a policy. At 12:42 PM, the Surveyor interviewed the FSD regarding the water supply and if beverages are considered food storage. The FSD stated that beverages would be considered part of food storage and the food storage policy would apply. At 1:35 PM, the MD provided the Surveyor with an invoice from 2017 for water and the MD stated he did not know about the water dated 2016, and did not provide any additional information regarding the process for water storage and the expiration date. The Food and Nutrition Services Policies and Procedures Policy, 4.7 Food Handling, effective 07//01/98 revealed: Foods are stored, prepared and served in a safe and sanitary manner., Purpose: To prevent bacterial contamination and possible spread of infections., 2.1. Employees wear disposable gloves when handling food. Disposable gloves are considered a single-use item and are discarded when damaged, soiled and after each use. 2.1.1. Employees must wash hands before putting on disposable gloves . The Food and Nutrition Services Policies and Procedures Policy, 2.2 Personal Hygiene, Effective 07/01/98, revealed: Food and Nutrition Services employees present a neat, clean, professional appearance and wear the uniform that meets the established guidelines of the department., Purpose: To maintain a professional appearance at all times. 7. Hair restraints such as hats, hair coverings, or nets are worn to effectively keep hair from contacting exposed food. Facial hair coverings are used to cover facility hair of a substantial length., 9. Disposable gloves are singe use and are changes between tasks. The Food and Nutrition Services Policies and Procedures, 5.6 Dry Storage, Effective 07/01/98 revealed: Products stored in dry storage areas are maintained in a safe and sanitary manner. Purpose: To prevent damage, spoilage, contamination, and infestation of products., 1. General Practices: 1.1 All shelves storage racks, and platforms are at least six inches off the floor .,13. Routine cleaning and pest control procedures are followed., 2. 2.2 Food is stored and rotated following first- in-first- out procedures., 2.3 Food stock is dated on the day of receipt. Items that are removed from the original box are individually dated. 2.4 Dented cans that are deemed unusable are separated from stock and clearly marked for return., 2.6 Open packages are stored in closed containers, tightly secured with ties or in food quality storage bags and include the use by date . The Food and Nutrition Services Policies and Procedures, 4.6 Hand Washing, Effective 07/01/98 revealed: Hand washing is performed frequently and using correct hand washing technique, Purpose: To minimize the spread of Disease., Process: 1. Handwashing is performed: 1.2, Before putting on disposable gloves to begin a task that involves food; 1.3, During food preparation, as often as necessary to clean soiled hands and exposed portions of arms, 1.7 After contacting any soiled equipment or utensils, 1.8, When moving from one task to another. The Food and Nutrition Services Policies and Procedures, 5.7 Refrigerated/Frozen Storage, Effective 07/01/98, revealed: Food stored under refrigeration/freezer storage is maintained in a safe and sanitary manner, Purpose: To prevent damage, spoilage, and contamination of products. Process: 1. Refrigeration: 1.4 All foods are labeled with name of product and the date received and use by date once opened. Manufacturer use by dates are used until opened. 1.11 Refrigeration units are kept clean and organized. Cleaning is routinely scheduled and completed. A review of the Facility Job Description for the Dining Services Director/Account Manager revealed: Manages the dining services program in a single site according to [management company] policies and procedures, and federal/state requirements. Provides leadership, support and guidance to ensure that food quality standards, inventory levels, food safety guidelines and customer service expectations are met. Review of the Emergency Water Supply Policy, provided by the MD on 03/23/22 at 10:00 AM, revealed: Policy: [Facility] will provide a safe and healthful environment for all resident, staff and visitors., Purpose: To establish procedure in the event of a loss of water supply., The following Action Steps will be taken: 8:39-17.2(g)

Based on interview, medical record review, and review of facility documentation, it was determined that the facility failed to: a.) follow the facility policy for Activities of Daily Living (ADL's), and b.) ensure that a resident had the right to make choices about aspects of his/her life in the facility that were significant to the resident. Specifically, the facility failed to identify and honor a resident's bathing request. This deficient practice was identified for 1 of 27 residents reviewed (Resident #50) and was evidenced by the following: On 03/17/22 at 9:50 AM, the Surveyor observed Resident #50 in bed with their eyes closed. On 03/17/22 at 12:19 PM, the Surveyor returned to Resident #50s room during the lunch meal, and observed a Friend of Resident #50 that was visiting at the bedside. The Friend informed the surveyor he had been trying to get Resident #50 a shower for the past two months. The Friend stated that the facility had not been able to accommodate Resident #50's preference for a shower. A Review of Resident #50's medical record revealed the following: The Admission Face Sheet (an admission summary) reflected that Resident #50 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Quarterly Minimum Data Set (MDS) an assessment tool dated 02/04/22, revealed that Resident #50 was alert and able to make her/his needs known. Resident #50 scored 14/15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. Section G of the MDS assessment which referred to Activities of Daily Living (ADLs), revealed that Resident #50 was totally dependent on staff for all ADLs including bathing. Section E of the MDS which addressed behavior, was coded 0 which indicated that Resident #50 did not exhibit any behavior. Section E 0800 which referred to rejection of care was coded 0 which indicated that Resident #50 was compliant with all care. A review of the on-going care plan for ADL care, included the goal that Resident #50 would improve current level of functioning in bathing, grooming/personal hygiene. The care plan for preferred activities indicated under focus, [Resident #50] stated that it was important that [he/she] had the opportunity to engage in daily routines that were meaningful relative to their preferences. The goal: [Resident #50] will plan and choose to engage in preferred activities was implemented on 11/02/21. Review of the interventions included: It is important to me to choose between a tub bath, shower, bed bath or sponge bath. It is important for me to have family or a close friend involved in discussions about my care. On 03/17/22 at 12:41 PM, the Surveyor interviewed the Licensed Practical Nurse (LPN) regarding the facility shower schedule process. The LPN stated that showers were scheduled during the 700 AM -3:00 PM and 3:00 PM -11:00 PM shifts. The LPN stated the Certified Nursing Assistants (CNAs) were responsible to complete the showers. Upon inquiry to the LPN regarding where the CNAs would document that a shower was provided, she indicated that the CNAs would document on the kiosk (computer system) used by the facility to document ADLs care provided. She further stated that ADLs care can be viewed under the Tasks section of the electronic medical record. On 03/17/22 at 12:49 PM, a review of the CNA's assignment book revealed that Resident #50's shower was scheduled on Tuesday and Friday on the 300 PM - 11:00 PM shift. The Surveyor interviewed one of the CNAs assigned to the unit regarding documentation in the kiosk. The CNA explained the process would be if the task was completed the documentation would be in green, and if the task was not completed, the documentation would be in pink. The CNA reviewed the bathing task for Resident #50 from March 1 through March 17, 2022 with the Surveyor. The documentation was observed in pink, which indicated that the bathing task had not been completed. A further review of the ADLs sheet provided by the facility confirmed that Resident #50 had not received a shower for the past two months. On 03/18/22 at 8:53 AM, the Surveyor observed Resident #50 in bed. Resident #50 was awake and alert and the Surveyor interviewed the resident at that time. The Resident stated stated that he/she had not had a shower for two months and would like to take a shower. On 03/18/22 at 9:58 AM, the Surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that her role was to oversee staff, assist with care, administer medications if the nurse called out, attend care conference with other disciplines and families, rounding with the wound nurse every Thursday, and to communicate with residents and assist with care planning. She further stated that staff would inform her of any complaints, and the family would also inform her of any issues that needed to be addressed. The Surveyor inquired to the LPN/UM regarding Resident #50's request for shower. The LPN/UM acknowledged that she had been informed by the LPN assigned to the low hall of Resident #50's about the request for a shower, and she had informed the 3:00 PM -11:00 PM Nurse. On 03/18/22 at 10:10 AM, the Surveyor interviewed the LPN assigned to the low hall about the process for shower. The LPN stated that the CNA would ask/inform the resident of the shower and if the resident refused, the CNA would inform the nurse, then the nurse would document into the notes that the resident had refused the shower. A review of the Nurse's Notes from 03/01/22 to 03/17/22 failed to indicate that a shower was offered to Resident #50, and refused on the following dates: 02/01/22, 02/04/22, 02/08/22, 02/11/22, 02/15/22, 02/18/22, 02/22/22, 02/25/22, 03/01/22, 03/04/22, 03/08/22, 03/11/22 and 03/15/22. On 03/17/22, a late entry was entered for 03/15/22, which revealed that Resident #50 had refused a shower on 03/15/22 (The resident was not provided with approximately sixteen showers). On 03/18/22 at 10:40 AM, the Surveyor requested the February's ADLs documentation from the LPN/ UM. The Unit Manager and the Assistant Director of Nursing indicated that they could not print the documentation as requested. At 12:55 PM, partial documentation was provided by the MDS Coordinator which confirmed that Resident #50 had not had a shower as scheduled for the last two months. On 03/22/22 at 9:15 AM, the Surveyor observed Resident #50 in bed. An interview with Resident #50 at that time revealed the resident denied refusing a shower on 03/15/22. Resident #50 stated, Of course I wanted to take a shower. On 03/22/22 at 10:09 AM, during an interview with Resident #50 in the presence of the UM, Resident #50 revealed that he/she had not had a shower since he/she had been at the facility. Resident #50 stated, Of course I would like to take a shower. I need a special chair and stated Would that be a scheduled shower? On 03/22/22 at 10:17 AM, the Surveyor reviewed the Nurse's Notes and could not locate documentation that Resident #50 had refused a shower on 03/18/22. The UM confirmed that the Nurse's Notes did note did not reflect that Resident #50 had refused a shower on 03/18/22 as scheduled. On 03/23/22 at 9:36 AM, the Surveyor interviewed Resident #50 and inquired as to how it felt not to having his/her scheduled shower, Resident #50 replied, I felt that was negligence on the part of the nursing home. On 03/28/22 at 9:51 AM, the Survey Team conducted a meeting with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing. The DON stated that when a resident was scheduled to have a shower, the CNA was responsible to communicate with a nurse if the resident refused. A review of the facility provided policy for, Activities of Daily Living revised 06/01/21, stated in part: Based on the comprehensive assessment of a resident, and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's activities of daily living ADL'S activities are maintained or improved and do not diminish unless circumstances of the individual's clinical condition demonstrate that a change was unavoidable. Activities of daily living (ADLs) include Hygiene-bathing, dressing, grooming, and oral care Purpose: To ensure ADLs are provided with accepted standards of practice, the care plan, and the patient's choices and preferences. Under Practice Standards the following were noted: Patients are assessed upon admission, quarterly, and with a significant change to identify his/her status in all areas of ADLs, risks for decline in any ADL ability to improve in identified ADLs. The care plan will address the patient's ADL needs and goals, including the provision of ADLs if the patient is unable to perform ADLs. A patient who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene. ADL care is documented every shift by the nursing assistant. The licensed nurse will document ADL care he/she provided, when applicable. NJAC 8:39- 4.1(a)22

Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to: a.) follow the facility policy for Advance Directives to ensure a complete and updated Advance Directive was maintained in a resident's medical file, and b.) inform and offer educational material regarding Advance Directives. This deficient practice was identified for 1 of 1 resident (Resident #2) who was reviewed for Advance Directives. The deficient practice was evidenced by the following: On 03/17/22 at 9:43 AM, the Surveyor observed Resident #2 in their room with their spouse. Resident #2 spoke to the Surveyor and was confused at times. A review of Resident #2's medical records revealed the following: The Admission Record revealed Resident #2 had been admitted to the facility with diagnoses, which included but were not limited, to dementia without behavioral disturbance, [CONDITION(S)] (stroke-like attack wherein symptoms resolve within 24 hours), depression, lack of coordination, [CONDITION(S)] (elevated blood potassium), hypertension (elevated blood pressure), abnormal gait and mobility, and major depressive disorder. The most recent Quarterly Minimum Data Set (MDS) an assessment tool, dated 03/11/22, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated the resident was cognitively intact, and that family or significant other participated in goal setting. The on-going Care Plan (CP) revealed a focus area that the resident has an established advanced directive initiated 09/04/20 with interventions which included full code (full support provided if a person has no heartbeat or stops breathing); all opportunities for expression of feelings; and inform resident/patient and/or healthcare decision maker of any change in status or care needs. On 03/18/22 at 9:37 AM, the Surveyor reviewed a form located in Resident #2's medical chart. The Resident's name and a note was observed in the upper right-hand corner '9/2/20 Full Code' with no other information filled out and there was no signature. The form indicated to 'circle: DNR [Do Not Resuscitate] DNH [do not hospitalize] DNI [do not intubate]; the form included the following sections to be filled out: 1. Reason for the DNR/DNH/DNI order; 2. Discussion of DNR/DNH/DNI status has occurred with resident - family/responsible party - nursing staff - other; 3.) discussion of DNR/DNH/DNI order has not taken place with family because .; 4.) Intervention aimed at curing the resident or restoring the resident to a better than present state of health are deemed futile, of no medical benefit, and hence medically inappropriate. The dying process is irreversible. Resuscitation to prevent or reverse death, when it occurs , would only impose additional burden and discomfort upon the resident without any reasonable hope of benefit. Therefore, I am ordering a. emphasis on comfort, support and symptom control, b. do not resuscitate, c. do not hospitalize, d. do not intubate, e. the resident is not to be disturbed with tests, unless the information thereby obtainable is expected to be utilized to increase the resident comfort or otherwise benefit the resident, f. additional orders. These orders are based upon a sound medical assessment, after consultation with the resident/responsible party of the resident's condition. On 03/18/22 at 9:46 AM, the Surveyor reviewed the Initial Services Assessment and Documentation form, dated 09/4/20 and documented by the previous Social Worker (SW), which indicated Resident #2 was a DNR do not resuscitate. A review of the Social Services Assessment and Documentation quarterly forms dated 12/04/20, 03/08/21, 06/06/21, 09/07/21, 12/02/21, and 03/13/21, all included but were not limited to the following information: 5. Resident Rights / Healthcare Decision Making / Advance Directives b. Advance Directives (e.g. Living Will, Healthcare Power of Attorney or Healthcare Proxy) in place? NO c. Additional conversation regarding advance care planning provide NO d. opportunity to complete advance directive offered YES e. Separate Healthcare Orders (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] ? NO Resident Rights / Advance Directive Comments, g. Use to further elaborate on healthcare decision making [area left blank]. On 03/18/22 at 9:49 AM, the Surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN UM) on the 2nd floor. The LPN UM stated that a resident's Advance Directive would be documented in the computer, and all updates would be the responsibility of the SW. The LPN UM stated it was important for residents to have Advance Directives so the staff would know what the residents' wishes were. On 03/18/22 at 10:30 AM, the present SW stated that Advanced Directives sometimes would be completed through the admissions department, or if the family wanted to change anything, the facility will have the Nurse Practitioner (NP) address changes along with the SW. The SW stated Advance Directives were important because the resident needed to be able to voice their rights and decisions. The SW stated the Advance Directives would be reviewed every month by the NP or SW. On 03/18/22 at 10:41 AM, the Surveyor reviewed a progress note dated 09/2/20 entered by the NP which revealed Full Code. The progress note revealed she had spoken to Resident #2's daughter on the phone from 11:30 am to 11:47 am and that the daughter was looking for the living will. The NP's progress notes further revealed that in the interim, Resident #2 would be made a Full Code as the daughter tried to locate the Advance Directives or living will documents. On 03/18/22 at 10:48 AM, the Surveyor reviewed the progress notes in Resident #2's medical records and was unable to find any follow up regarding Advanced Directives to date or follow up with the resident's daughter. On 03/22/22 at 9:18 AM, during a follow-up interview, the SW stated Resident #2 was a full code and knew that because he had asked the business office. The SW stated he would have to look for any paperwork regarding the resident's code status or Advance Directives. On 03/22/22 at 9:36 AM, the Director of Social Services (DSS) stated that when a resident was admitted to the facility, social services would ask if they had any Advance Directives. If the resident did not have one, they would be offered to formulate an Advance Directive, and it would be discussed during the quarterly care conference. The DSS added that documentation of the discussion of Advance Directives should be in located in the progress notes because it was important to know what a resident's wishes were. The DSS stated she had no explanation as to why no one had followed up on the Advance Directive for Resident #2. On 03/22/22 at 10:07 AM, the Surveyor attempted to contact Resident #2's daughter. On 03/22/22 at 11:26 AM, the Surveyor attempted to ask Resident #2 about an Advance Directive, wishes or life choices. The resident was confused and was unable to answer. On 03/24/22 at 10:34 AM, the SW stated he would review the file to see if anything was updated in the chart about Advanced Directives. The SW further stated that the process was to ask the family or resident upon admission, and that would be on the UDA [Initial Services Assessment and Documentation] assessment. The SW further stated that the health care decision and Advance Directives would be tracked via the computer system, or there should be a copy in the file. The SW stated when he completed his assessment, that he asked the Resident's daughter and he was unsure of the date. The SW stated he did not document in the medical record and that the assessment was the quarterly assessment. He stated there was no documentation who attended, and the SW was unable to confirm who was at the meeting, or who he spoken to. The SW further stated that the conversation was not documented, and that he would just check off the questions on the assessment form. On 03/24/22 at 11:05 AM, the DSS stated she would review Advance Directives during care conference. She stated that Advance Directives would be addressed during the initial assessment and during care conferences that were done quarterly, and the attendants should be listed in the progress notes. The DSS reviewed the 09/04/20 progress note and acknowledged the note reflected Resident #2 was a DNR, but the following note reflected Resident #2 was a full code. She stated the documentation did not follow up as to when the subsequent Social Worker completed the quarterly assessment, and that the Social Worker listed the resident as not having an Advanced Directive. The DSS stated per the documentation there was no proof that we [the facility] did what we were supposed to do. She stated that copies of the Advance Directive should be kept in the resident's chart, and she had no explanation as to why there was no education or information provided to the resident, or daughter regarding an Advance Directive. On 03/24/22 at 11:33 AM, the Surveyor made a second attempt to contact Resident #2's daughter but there was no answer. A review of the facility provided policy and procedure, Health Care Decision Making revision 3/1/22, revealed Policy: it is the right of all patients / residents to participate in their own health care decision making including the right to decide whether they wish to request, accept, refuse, or discontinue treatment, and to formulate or not formulate an Advance Directive. Centers must: inform and provide written information to all patients concerning the right to accept or refuse medical or surgical treatment and the patient's option formulate an advance directive; provide a written description of the centers policies to implement advance directives; approach a capable patient who does not have an advance directive upon admission, the patient will be approached by the SW or another designated staff on admission, quarterly, and with change in condition to discuss whether he/she wishes to consider developing an advance directive; inquire with the individual's patient representative if the patient is incapacitated at the time of admission as to whether an advance directive has been complete/executed in accordance with state law; and establish mechanisms for documenting and communicating the patient's choices to the interprofessional team and staff responsible for the patient's care. Advance Care Planning: an ongoing process of communication between patients and their healthcare decision makes to understand, reflect on, discuss, and plan for future healthcare decisions for a time when patients are not able to make their own healthcare decisions. Advance care planning includes two key parts: 1. Face-to-face conversations with physician, healthcare professional and patients or their healthcare decision makers to discuss advance directives and treatment decisions; and 2. Documenting treatment or wishes preferences. Advance Directive: written instruction, such as a living will or durable power of attorney for health care, recognized under state law relating to the provision of health care. Instructive Directive: Living will or similar state form that is used to document the medical treatment wishes. It serves as information for the family, physician, and/or surrogate decision maker to base health care decisions on the patient's personal desires for treatment. Practice Standards: 1. Upon admission, determine whether the patient has a copy with them, make copies, place in medical record, and notify interprofessional team. 1.1.1.1 request that patient/patient representative bring the documents to the Center [facility] as soon as possible. 1.2 If the patient does not have an advance directive: 1.2.3 provide advance directive information. 2. Throughout the stay, advance care planning conversations will be conducted as part of the care plan process and with significant change in condition to identify, clarify, and review existing advance directives and/or portable medical orders and determine whether the patient wishes to change or continue these instructions. On 03/25/22 at 12:56 PM, the concerns were discussed with the facility. The facility had no additional information to provide. NJAC 8:39-4.1(a)(2)(4), 9.6(a)

Based on observation, interview, record review and review of pertinent documents, it was determined that the facility failed to: a.) administer oxygen per the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] .) ensure that all oxygen supplies were changed, labeled and dated weekly for 4 of 5 residents sampled for respiratory/oxygen, and c.) post cautionary signage to indicate that oxygen therapy was in use for 4 of 5 residents reviewed for oxygen/respiratory (Resident #36, #17, # 63 and Resident #27). The deficient practice was evidenced by the following: 1. On 03/17/22 at 10:13 AM, the Surveyor observed Resident #36 resting in bed with eyes open wearing oxygen (O2) by way of nasal cannula (tubing used to deliver oxygen). The O2 was connected to an oxygen concentrator (an electronic device that removed nitrogen from room air and increased the oxygen concentration) that was sitting beside the bed and set to deliver 3.5 liters of oxygen per minute. On 03/18/22 at 9:24 AM, the Surveyor observed Resident #36 resting in bed with his/her eyes closed. Resident #36 was observed wearing O2 by way of nasal cannula. The oxygen was connected to an oxygen concentrator sitting next to the bedside and the concentrator was set to deliver 4.5 liters of O2 per minute. A review of Resident #36's medical record revealed: the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician order dated 04/13/19 revealed O2 at 3 liters per minute nasal cannula continuously 18-24 hours daily every shift, O2 tubing change weekly, label each component with date and initials every night shift every Saturday and label each component with date and initials. A review of the Quarterly Minimum Data Set (MDS an assessment tool) dated 01/22/22, revealed that Resident #36 was cognitively intact and required limited assistance with activities of daily living. On 03/18/22 at 11:32 AM, the Surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that she was not too sure of the setting for the O2 and that she indicated that she checked the oxygen concentrator this morning. On 03/18/22 at 11:35 AM, the Surveyor accompanied by LPN #1 into Resident #36's room only to verify that the O2 was connected to the oxygen concentrator with a flow rate of 4.5 liter per minute. The surveyor observed that the O2 tubing was not labeled with a date and was resting on the floor. The surveyor also observed the humidifier bottle (a medical device used to humidify O2, increases humidity or moisture and decrease dryness) was dated 03/04/22. The Surveyor observed that there was no cautionary signage posted at the door to indicate that O2 was in use. LPN #1 confirmed that the flow rate was set to deliver 4.5 liters per minute and that she would check the physician order and adjust the flow rate. On 03/18/22 at 11:40 AM, the Surveyor conducted another interview with LPN #1 who confirmed that she was responsible for Resident #36 that morning and that the 11:00 PM -7:00 AM shift was responsible to change the O2 tubing and humidifier bottled every Saturday. LPN #1 confirmed that Resident #36's order was to receive O2 at 3 liters per minute. On 03/25/22 at 8:55 AM, the Surveyor interviewed the LPN (LPN #2) who worked the 11:00 PM-07:00 AM shift. LPN #2 stated that she had not been at the facility for the last two weeks and that the other nurse that covered the shift should have changed and dated the O2 tubing. LPN #2 indicated that upon return to work she did not check to ensure that the O2 tubing was changed as it was the facility's policy for the O2 tubing to be changed every week on Saturday. 2. On 03/17/22 at 10:15 AM, the Surveyor observed Resident #17 in bed. Resident #17 had the O2 on and the O2 tubing was dated 03/04/22. The surveyor observed the flow rate set to deliver 3.5 liters O2 per minute. The surveyor observed that there was no cautionary signage posted at the door to inform of O2 usage in that room. The Surveyor reviewed Resident #17's medical record which revealed the following: Resident #17 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order sheet dated 11/28/21 reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order continued to reveal that O2 tubing was to be changed weekly and that the staff was to label each component with date and initials every shift on every Saturday. On 03/18/22 at 11:42 AM, the Surveyor interviewed the LPN #1 regarding the process for oxygen administration and use of O2. LPN#1 revealed that the nurse should ensure that cautionary signage was posted at the entrance door to inform of O2 being in use and to check the flow rate. She further stated the 11:00 PM - 7:00 AM shift was responsible to change the tubing every Saturday. The LPN admitted that she did not check the date on the O2 tubing. On 03/18/22 at 11:52 AM, the Surveyor observed Resident # 17 in bed, awake and alert with the head of the bed elevated. Resident #17 was receiving O2 by way of a nasal cannula connected to the O2 concentrator next to the bed. The oxygen concentrator was set to deliver 3.5 liters. The O2 tubing was dated 03/04. According the facility policy the O2 was to be changed every Saturday, the oxygen tubing had not been changed for two weeks, and the humidifier bottled was not dated. The surveyor accompanied LPN #1 to Resident #17's room and both the surveyor and the LPN #1 observed that the O2 concentrator was set to deliver 3.5 liters per minute. The nurse then verified the physician's order and adjusted the flow rate to 3 liters per minute as ordered. 3. On 03/17/22 at 10:18 AM, the Surveyor observed Resident #63 sleeping in bed with O2 being administered at 3 liters per minute by nasal cannula tubing which was connected to an O2 concentrator. The Surveyor observed that the nasal cannula tubing was dated 02/27/22. The Surveyor also observed that there was no cautionary signage posted on Resident #63's door to indicate O2 was in use. On 03/17/22 at 12:38 PM, the Surveyor, in the presence of another Surveyor, observed Resident #63 sitting up in the bed without O2 by nasal cannula tubing being administered. The Surveyor attempted to interview Resident #63 who was unable to participate in the interview due to cognitive deficits. The Surveyors observed the nasal cannula tubing, dated 02/27/22, was lying on the floor next to Resident #63's bed. On 03/18/22 at 9:14 AM, the Surveyor observed Resident #63 sleeping in bed with O2 being administered at 3 liters by minute by nasal cannula tubing. The Surveyor observed that the tubing was dated 02/27/22. On 03/18/22 at 9:42 AM, the Surveyor reviewed Resident #63's medical record. A review of Resident #63's Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #63's quarterly MDS, an assessment tool used to facilitate the management of care, dated 02/14/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 99, which indicated that Resident #63 was unable to complete the interview. Further review of the MDS indicated that Resident #63's skills for daily decision making were severely impaired. A review of Resident #63's Medication Review Report included the following physician's order: O2 2 LPM via nc (nasal cannula) may titrate (adjust the amount until the desired effects are achieved) up for po <92%, RR (respiratory rate) > 20 or feelings of breathlessness. A review of Resident #63's care plan indicated that the resident did not have a care plan for the use of oxygen. On 03/18/22 at 11:22 AM, in the presence of another Surveyor, the Surveyor asked the LPN #2 to inform the Surveyors what date she observed on Resident #63's nasal cannula tubing. LPN #2 confirmed that the date on the nasal cannula tubing was 02/27/22 and stated that the tubing was usually changed every Saturday on the 11 PM -7 AM shift, and that Resident #63's nasal cannula tubing should have been changed. She added that she always looked at the flow rate of the O2 and that sometimes she looked at the date on the tubing. The Surveyor then informed LPN #2 about the observation that the two surveyors made of Resident #63's nasal cannula tubing on the floor on 03/17/22. LPN #2 stated that if the nasal cannula was on the floor that the tubing should have been changed. The Surveyor then asked LPN #2 if there should be a sign on Resident #63's door that would indicate O2 was in use. LPN #2 confirmed that there was not a cautionary sign on the door and stated that she believed there should be one. On 03/18/22 at 11:33 AM, in the presence of the LPN #2, the Surveyor asked the Unit Manager (UM) of the second floor what date she observed on Resident #63's nasal cannula tubing. The UM confirmed that the date on Resident #63's nasal cannula tubing was 02/27/22 and revealed that the tubing should have been changed. On 03/22/22 at 12:04 PM, the Surveyor interviewed the UM who confirmed that Resident #63 did not have a care plan for O2 use and that Resident #63 should have had one. 4. On 03/17/22 at 9:58 AM, the Surveyor observed Resident #27 sleeping in bed with O2 at 2 lpm by nasal cannula tubing. The Surveyor observed that the nasal cannula tubing was dated 02/27/22. The Surveyor observed that a water bottle that was connected to the O2 concentrator was dated 2/21. The Surveyor also observed that there was not a cautionary sign on Resident #27's door to indicate O2 was in use. On 03/18/22 at 9:25 AM, the Surveyor observed Resident #27 in bed with O2 being administered at 2 lpm by nasal cannula tubing. The Surveyor observed that the tubing was dated 02/27/22. The Surveyor observed that a humidification water bottle that was attached to the O2 concentrator was dated 2/21. The Surveyor interviewed Resident #27 who stated that he/she used the O2 mostly at night but also used it during the day. On 03/18/22 at 11:20 AM, the Surveyor reviewed Resident #27's medical record which revealed the following: The Admission Record face sheet reflected that the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS, an assessment tool used to facilitate the management of care, dated 01/20/22, reflected that the resident had a BIMS score of 15 out of 15, which indicated that Resident #63 was cognitively intact. The Medication Review Report (MRR) included the following orders: O2 at 2L/min via nasal cannula every shift for [CONDITION(S)]; O2 tubing change weekly and label each component with date and initials every night shift every Sunday. The Care Plan, with a created date of 07/30/21, indicated that the resident had a care plan for [CONDITION(S)] which included the use of O2. On 03/18/22 at 11:25 AM, in the presence of another Surveyor, the Surveyor asked LPN #2 to explain to the Surveyors date she observed on Resident #27's nasal cannula tubing and water bottle. LPN #2 confirmed that the date on the nasal cannula tubing was 02/27/22 and the date on the water bottle was 2/21. LPN #2 stated that the nasal cannula tubing was usually changed every Saturday on the 11-7 shift and that Resident #27's nasal cannula tubing and water bottle should have been changed. She added that humidity water bottle was changed at the same time the nasal cannula tubing was changed. The Surveyor then asked LPN #2 if there should be a cautionary sign posted on Resident #27's door that would indicate oxygen was in use and LPN #2 confirmed that there was not a sign and believed there should be a sign. On 03/18/22 at 11:34 AM, the Surveyor asked the UM of the second floor what dated was posted on Resident #63's nasal cannula tubing and water bottle. The UM confirmed that the date on Resident #63's nasal cannula tubing was 02/27/22 and the date on the water bottle was 2/26. The UM admitted that the tubing and water bottle should have been changed and added that it should be changed weekly and that it was usually done on Saturday evening and believed that it gets documented. The Surveyor then reviewed Resident #27's Treatment Administration Record (TAR) which indicated that on 03/6/22 and 03/13/22 Resident #27's oxygen tubing was documented to have been changed by the nurse. On 03/18/22 at 12:02 PM, the Surveyor interviewed the UM. The UM stated that the nurses had signed that they changed the tubing but that all she knew was that the date on the nasal cannula tubing did not match what the nurses signed for on the TAR. An interview was conducted with the Director of Nursing (DON) on 03/28/22 at 11:20 AM. The DON stated that the nurses should be checking the flow rate of the oxygen at least every shift. Her expectations were that the oxygen tubing and humidifier bottled would be changed, dated and labeled weekly. A review of the facility provided policy titled Oxygen: Nasal Cannula with a revision date of 06/1/21, included the following: 1. Verify order. 2. Determine appropriate oxygen source and need for humidification by the using the following table . 3. Gather supplies: 3.2 Nasal cannula labeled with date of initial set-up . 3.8 No Smoking-Oxygen in Use sign . 6.Post No Smoking-Oxygen in Use sign on patient's door 10. If humidifier is used: 10.1 Label with date . 11.set the flow rate to the prescribed liter flow . 16. Replace disposable set-up every seven days. Date and store in treatment bag when not in use . N.J.A.C. 8:39-11.2 (b); 27.1(a)

COMPLAINT # NJ 2 Based on interviews, Medical Records (MR) review, and review of other pertinent facility documents on 9/19/2019, it was determined that the facility staff failed to administer medication correctly, according to the Physician's orders, for 1 of 3 sampled residents (Resident #2). The wrong medication was administered to a resident on 9/5/2019, which resulted in a hypotensive episode and treatment requiring hospitalization . In addition, the facility staff failed to follow their own policy titled The Seven Rights of Medication Administration for 1 of 3 sampled residents (Resident #2). This deficient practice is evidence by the following: 1. According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 8/16/2019, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12/15, indicating that Resident #2 was moderately cognitively impaired. The MDS also indicated Resident #2 was extensive assist for Activities of Daily Living (ADLs). Review of the Medication Review Report for medication orders On or After Date 9/19/2019, revealed Resident #2 was on the following medications: [REDACTED]. Review of the Facility Reportable Event (FRE) dated 9/5/2019, revealed a medication error report with an event date and time of 9/5/2019 at 9:00 a.m. Under Narrative it showed the following: Resident was given her roommates morning BP (blood pressure) medications in error and experienced an orthostatic episode. Medical Doctor and family made aware. Nurse Practitioner (NP) saw patient immediately. Further review of the FRE revealed the following under interventions implemented: Resident's vital signs being monitored q (every) 15 minutes x (times) 24 hours, IV (Intravenous) fluids, in bed with feet and head elevated. O2 (oxygen) administered. Review of the investigation Summary and Conclusion dated 9/5/2019 documented by the Director of Nursing (DON) revealed the following: Resident #2 received [MEDICATION NAME] ER (extended release) 30 mg and [MEDICATION NAME] 4 mg which he/she is not on. He/she also received [MEDICATION NAME] 50 mg which he/she is on, and Losartan Potassium 50 mg which he/she is on at 100 mg. An Orthostatic episode resulted. The resident was seen by the NP who was in the building. Treatment was administered and the resident was later sent out to the hospital. In addition, the DON documented the following: .while sitting in her wheelchair he/she experienced an orthostatic episode. He/she was responsive at this time, but confused, BP (blood pressure) and SpO2 (an estimate of the amount of oxygen in the blood) were low. NP was called and came to assess resident immediately. Oxygen applied, IV (intravenous) fluids started, and resident was placed in bed with feet and head elevated. During an interview on 9/19/2019 at 12:40 p.m., with the Licensed Practical Nurse (LPN #1) who was the nurse preceptor for the Registered Nurse (RN #1), reported she watched RN #1 pour the medications then put them in applesauce. At that time, the resident across the hall called for attention. LPN #1 stated to RN #1 just stay here I'll be right back. LPN #1 left RN #1 standing at the med cart and went across the hall to check on the resident. When LPN #1 came out of the other resident's room she noticed RN #1 was not standing at the med cart, she was in the resident's room. When LPN #1 went into the room RN #1 was on B side of the room. LPN #1 stated Please tell me you did not give those medications to B bed. RN #1 responded yes I gave the meds to B bed. LPN #1 said No they were for A bed. During an interview on 9/19/2019 at 10:56 a.m., the DON reported, RN #1 said she did not check the resident's name bracelet. In addition, the DON stated RN #1 was taken off the floor immediately. She did not administer any medications to any other residents after the medication error. I spoke to her than I asked her to leave. I told her not to report the next day and HR (Human Resources) later called her and told her not to return. According to New Jersey Universal Transfer Form it showed Resident #2 was transferred to the hospital on [DATE] at 9:00 p.m., with a pulse of 75 and a blood pressure of 88/46. According to the facility staff Resident #2 did not return to the facility. Review of the facility policy titled The Seven Rights of Medication Administration. undated, established the following: The Seven Rights of Medication Administrations: 1. Right Patient 2. Right Drug 3. Right Time 4. Right Route 5. Right Dose 6. Right Reason 7. Right Documentation. N.[NAME][NAME]C. 8:39-29.2(d)